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Medical  Problems  of  Legislation 


Being  the  Papers  and  Discussions 
Presented  at  the  XLI  Annual  Meeting 
of  the  American  Academy  of  Medi- 
cine, held  at  Detroit,  Mich,  June 
9-12,  1916. 


Easton,  Pa.: 

American  Academy  of  Medicine  Press 

1917 


^l)ec^1 


The  Medico-Social  Problems  Library, 
VII. 


The  American  Academy  of  Medicine  is  not  responsible  for  the  sentiments 
exprest  in  any  paper  or  article  presented  to  it. 


PREFACE. 

The  boundary  between  legislation  and  medicine  is  extensiv 
and  extending.  With  each  succeeding  session  of  the  legislatures 
these  problems  become  more  varied  and  complicated.  It  begins 
with  prescribing  the  requirements  for  entering  upon  the  practice 
of  medicine,  continues  in  regulating  the  practice  in  important 
directions  after  the  student  has  become  a  physician,  as  shown  by 
the  laws  regulating  criminal  malpractice,  prescribing  of  narcotics 
and,  more  recently,  by  the  various  forms  of  welfare  insurance. 
Thus  the  contact  between  the  physician  himself  and  legislation 
is  important  and  intimate.  Then  there  are  the  regulations 
grupt  together  under  public  health  laws  and  the  medical  ques- 
tions to  be  determined  in  legislating  for  the  care  of  defectiv 
classes,  which  are  additional  examples  of  the  intimate  relation- 
ship between  medicine  and  legislation. 

This  volume  presents  and  discusses  some  of  these  problems, 
being  the  transactions  of  the  forty-first  annual  meeting  of  the 
American  Academy  of  Medicine.  The  papers  have  already 
appeard  in  the  official  organ  of  the  Academy,  the  Journal  of 
Sociologic  Medicine,  and  are  gathered  together  in  a  single  volume 
for  the  convenience  of  those  who  may  desire  to  refer  to  these 
papers  apart  from  other  articles  appearing  in  the  Journal. 


366673 


TABLE  OF  CONTENTS. 


Our  Social  Readjustments  and  the  Relation  of  the  State  to  Mother- 
hood and  Children.  By  George  A.  Hare,  M.D.,  Fresno,  Cal. 
{President's  Address.) 7 

Legislation  Affecting  the  Entrance  upon  the  Practice  of  Medicine: 

Legislation  Regulating  the  Practice  of  Medicine,  Preliminary  and 
Medical  Education.  By  N.  P.  Colwell,  M.D.,  Chicago,  Secretary 
of  the  Council  on  Medical  Education  of  the  American  Medical 
Association 24 

Examinations  for  License  to  Practise  and  Hospital  Interneship. 
By  John  M.  Baldy,  M.D.,  Philadelphia,  President  of  the  Bureau 
of  Medical  Education  and  Licensure  of  the  State  of  Pennsylvania.     37 

Legislation  Affecting  the  Status  and  Duties  of  Physicians: 

Legislation  Creating  Civil  Positions  for  Physicians.  By  John  B. 
McAlister,  M.D.,  Harrisburg,  Pa.,  President  of  the  Medical  So- 
ciety of  the  State  of  Pennsylvania 46 

Social  Insurance  against  Accidents  (Workmen's  Compensation  Laws). 
By  Frederick  L.  Van  Sickle,  M.D.,  Olyphant,  Pa 54 

Health  Insurance.  By  John  B.  Andrews,  Ph.D.,  New  York  City, 
Secretary  of  the  American  Association  for  Labor  Legislation ....     77 

Unemployment  Insurance.  By  Hon.  Rufus  M.  Potts,  Springfield, 
111.,  Insurance  Superintendent,  State  of  Illinois 90 

The  Relation  of  Medical  Benefits  of  Health  Insurance  to  Existing 
Health  Agencies.  By  B.  S.  Warren,  M.D.,  Washington,  D.  C, 
Surgeon  U.  S.  Public  Health  Service iii 

The  New  York  State  Sanitary  Code,  How  Enacted— Its  Scope  and 
Legal  Status.  By  Hermann  M.  Biggs,  M.D.,  Albany,  N.  Y., 
State  Commissioner  of  Health 125 

Interstate  Sanitary  Relations.  By  William  Colby  Rucker,  M.D., 
Washington,  D.  C,  Assistant  Surgeon-General,  U.  S.  Public 
Health  Service 131 

The  Drink  Problem  and  Legislation.     By  John  Koren,  A.B.,  Boston.   140 


Legislative  Protection  of  the  People  from  the  Evils  of  Patent  Medi- 
cines and  Medical  Fakers.  By  F.  F.  Lawrence,  M.D.,  D.Sc, 
LL.D.,  F.A.C.S.,  Columbus,  0 154 

Industrial  Legislation: 

Standards  Applicable  to  Child  Labor.  By  Helen  L.  Sumner,  Ph.D., 
Washington,  D.  C,  Assistant  Chief,  U.  S.  Children's  Bureau. . . .    164 

Women  as  Wage-earners.  By  Mrs.  Florence  Kelley,  New  York 
City,  General  Secretary,  National  Consumers'  League 176 

Housing  Reform  Through  Legislation.  By  Lawrence  Veiller,  New 
York  City,  Secretary,  National  Housing  Association 179 

Medicine  and  the  Industries.  By  George  M.  Price,  M.  D.,  New 
York  City,  Director,  Joint  Board  of  Sanitary  Control 183 

Legislation  for  Care  of  Exceptional  Cases: 

The  Physically  Defective.     By  B.  O.  Otis,  M.D.,  Boston 189 

The  State  and  the  Insane.  By  Richard  H.  Hutchings,  M.D.,  Ogdens- 
burg,  N.  Y.,  Superintendent,  St.  Lawrence  State  Hospital 209 

The  Necessity  for  Medical  Examination  of  Prisoners  at  the  Time  of 
Trial.  By  Paul  E.  Bowers,  M.D.,  Michigan  City,  Ind.,  Physician 
to  Indiana  Hospital  for  Insane  Criminals 220 


OUR  SOCIAL  READJUSTMENTS  AND  THE  RELATION 
OF    THE    STATE    TO    MOTHERHOOD    AND 
CHILDREN. 

By  George  A.  Hare,  M.D.,  Fresno,  Cal. 

We  have  met  this  evening  to  celebrate  the  forty-first  anni- 
versary of  the  founding  of  the  American  Academy  of  Medicine. 
I  will  not  attempt  to  recount  our  achievements,  for  society  has 
moved  so  rapidly  during  the  past  forty-one  years  that  should 
any  one  have  had  the  temerity  to  have  outlined  our  progress  he 
would  have  been  classed  as  a  dreamer  of  dreams. 

It  was  Morse  who  tried  to  forecast  our  progress  in  1819  by 
teaching  school  children  in  his  Universal  Geography  issued  in 
that  year  that  "All  settlers  who  go  beyond  the  Mississippi  River 
will  be  forever  lost  to  the  United  States." 

And  again  it  was  tried  in  1840  by  no  less  a  person  than  Daniel 
Webster  who,  in  one  of  his  eloquent  speeches  before  the  United 
States  Senate,  exprest  his  belief  that  the  Mississippi  River 
formed  the  Western  boundary  of  modern  progress  beyond  which 
American  civilization  could  hope  to  make  no  substantial  headway 
for  he  askt,  "What  do  we  want  with  that  vast  and  worthless 
area — that  region  of  savage  wild  beasts,  of  deserts,  of  shifting 
sands  and  whirling  winds,  of  dust,  of  cactus  and  of  prairie 
dogs?"  "To  what  use  could  we  ever  hope  to  put  those  great 
deserts  and  those  endless  mountain  ranges — what  could  we  ever  do 
with  that  western  coast — a  coast  of  three  thousand  miles — ^rock- 


bound,  cheerless  and  uninviting."  Even  Webster  had  no  dream 
that  the  children  of  his  day  would  see  a  Lincoln  Highway  unite 
the  undisputed  center  of  the  commercial  world  with  the  un- 
rivalled paradise  of  the  Pacific. 

As  an  illustration  of  our  rapid  progress  take  the  interesting 
problem  of  intelligent  quarantine.  Suppose  that  New  Orleans, 
during  a  scourge  of  yellow  fever  fifty  years  ago  had  had  a 
really  intelligent  health  officer,  who  would  have  considered  that 
physical  contact  with  a  person  dying  of  yellow  fever  involved  no 
danger  whatever,  and  who  would  have  considered  green  peas,  cu- 
cumbers and  water  melons  as  deliciously  harmless  as  they  really 
are,  and  permitted  them  freely  in  the  open  market,  and  should  have 
directed  his  energies  and  authority  toward  the  extermination  of 
the  stegomyia  mosquito.  Such  intelligence  would  have  caused 
him  to  be  considered  the  victim  of  hallucinations  and  a  fit  sub- 
ject for  the  insane  asylum.  But  when  society  gave  sufficient 
study  to  the  problem  of  control  of  infectious  diseases  it  found  the 
adoption  of  this  apparently  insane  idea  a  practical  necessity. 

Yellow  fever,  malaria  and  bubonical  plague  have  remained  un- 
changed, but  society  has  had  to  change  its  viewpoint,  and  to  con- 
sider them  no  longer  questions  of  green  vegetables,  foul  air  and 
evil  spirits,  but  rather  of  mosquitoes,  of  fleas,  and  of  bedbugs, 
no  longer  questions  of  dietetics  but  questions  of  entomology. 

But  I  hear  some  one  say,  we  had  to  change  our  view  point  in 
the  treatment  because  doctors  had  not  discovered  the  bacterial 
.cause  of  these  diseases.  All  right  then,  let  us  illustrate  the  changed 
view  point  of  society  by  citing  another  instance.  We  have  done 
a  wonderful  work  in  controlling  the  ravages  of  tuberculosis.  We 
certainly  have  discovered  its  bacterial  causation,  never  was 
conformation  to  Koch's  postulates  more  rigidly  demanded.  We 
have  educated  the  public  until  its  bacterial  cause  is  the  common 
knowledge  of  every  school  boy.  We  have  demonstrated  be- 
yond a  question  that  this  is  a  preventable  disease  and  should  no 
longer  be  the  white  plague  of  an  intelligent  civilization.  We  have 
lowered  the  death  rate  some,  but  the  real  problem  of  its  control 
and  its  eradication  is  yet  before  us. 


All  we  have  done  has  only  brought  us  face  to  face  with  the 
stern  truth,  that  the  control  of  tuberculosis  must  no  longer  be 
considered  a  medical  problem,  but  a  social  problem.  And  as  a 
social  problem  it  can  never  be  cured  until  we  treat  it  socially. 

And  society  will  treat  tuberculosis  in  a  social  way  only  when 
it  treats  all  sickness  in  a  social  way,  by  means  of  social  insurance. 
And  when  society  treats  all  sickness  by  insurance,  it  will 
find  that  the  suggestion  made  by  Chester  Rowell  is  true 
that  it  is  cheaper,  it  costs  less  cash,  to  supply  all  those  condi- 
tions necessary  for  keeping  people  well  enough  to  earn  their 
living,  than  it  is  to  support  them  and  their  families  when  they 
are  sick.  Then  and  only  then  will  the  problem  of  tuberculosis 
find  its  real  solution.  Is  this  an  insane  idea?  Well  we  must 
squarely  face  it,  for  social  insurance  is  the  problem  of  to-day, 
and  is  by  all  odds  the  largest  problem  before  the  medical  pro- 
fession. 

We  are  in  a  transitional  period,  the  individualistic  system 
with  its  individual  doctor,  its  individual  patient,  is  passing; 
and  in  its  place  we  will  soon  find  the  coUectivistic  method  as  is 
shown  by  the  present  tendency  to  social  insurance  which  has 
for  its  object  the  prevention  and  cure  of  sickness  on  a  coUectivistic 
plan,  just  as  society  now  prevents  and  cures  ignorance  by  means 
of  our  public  schools,  the  expense  of  which  is  a  coUectivistic 
and  not  an  individualistic  obligation. 

In  a  democratic  form  of  government  the  ignorance  of  one  is 
the  menace  all,  hence  the  education  of  each  at  the  expense  of 
all.  This  principle  applies  with  as  much  force  in  the  control 
of  all  infectious  diseases  as  it  does  in  the  control  of  ignorance. 
The  infection  of  one  is  the  menace  of  all,  hence  the  care  and  pro- 
tection of  each  should  be  at  the  expense  of  all;  and  protection 
of  society  against  tuberculosis  means  that  each  must  have  enough 
food,  clothing,  shelter,  rest  and  recreation  to  keep  his  vital  re- 
sistance above  the  invading  level  of  tuberculosis.  This  means 
employment,  wages,  reasonable  working  hours,  and  proper  care 
when  ill  from  accidental  causes.  It  means  that  society,  as  in- 
dividuals, demands  that  society,  as  a  whole,  distribute  the  causes 


lO 

of  poverty  and  suffering  by  intelligent  prevention,  rather  than 
by  our  present  method  of  treating  the  end  results,  suffering, 
sickness,  poverty  and  a  large  amount  of  crime,  at  an  enormous 
and  wasteful  expense,  or  by  a  heartless  and  wicked  neglect. 
Hence  we  have  the  foundation  of  social  insurance  laws  against 
sickness  and  unemployment.  It  is  just  as  sound  in  principle  and 
just  as  profitable  to  keep  people  well,  at  public  expense,  as  to 
keep  them  educated  at  public  expense;  it  is  quite  as  much 
in  the  interest  of  public  welfare  to  cure  sickness  as  to  cure  ignor- 
ance. Doesn't  this  idea  of  curing  sickness  at  public  e^tpense 
sound  like  socialism  and  if  so,  is  it  not  dangerous? 

Socialism  is  a  term  we  all  dislike,  but  in  using  it  as  a  label  to 
hinder  every  movement  in  the  interest  of  the  people  we  have 
rather  worked  it  overtime. 

A  railroad  commission  which  compelled  the  railroad  to  work 
for  the  interest  of  the  public  as  well  as  for  private  gains  was  social- 
istic. 

The  assumption  by  the  state  or  municipality  of  the  right  to 
control  the  building  of  tenement  houses  for  the  poorer  classes 
so  that  every  man,  woman  and  child,  shall  be  given  by  every 
owner  of  rented  property  sufficient  light  and  air  for  good  health, 
is  socialistic. 

The  compulsory  education  of  every  child  for  its  own  good 
and  the  good  of  the  state  at  the  expense  of  the  public,  is  socialistic. 

The  control  of  public  utilities  such  as  gas,  water  and  telephone 
companies,  depriving  them  of  the  power  to  charge  one  patron 
more  than  another,  or  to  make  in  any  cases  more  than  a  reason- 
able charge,  is  socialistic. 

Who  could  have  foreseen  that  the  same  progressive  forces 
which  called  the  American  Academy  of  Medicine  into  being  would 
compel  us  to  consider  in  such  rapid  sequence  the  topics  just  men- 
tioned and  many  others,  and  bring  us  face  to  face  with  such  popu- 
lar movements  as  industrial  insurance,  health  insurance,  mothers' 
insurance  and  other  national  movements  which  add  to  the  peace 
and  prosperity  of  our  commonwealth. 

These  efforts  at  social  readjustment,  based  on  the  principle 


II 

that  every  industry  should  share  the  losses  as  well  as  the  gains 
of  its  development  and  maintenance  are  so  sound  in  their  phil- 
osophy and  so  practical  in  their  results  that  since  1883,  when  they 
were  recognized  by  Germany,  they  have  found  expression  on  the 
statute  books  of  almost  every  civilized  nation. 

Social  insurance  is  so  important  to  the  medical  profession 
that  the  American  Medical  Association  recently  appointed  a 
special  committee  to  study  this  problem. 

The  State  Medical  Society  of  California  at  its  meeting  in 
April  last  appointed  a  state  committee  on  social  insurance  and  re- 
quested every  county  society  to  appoint  a  similar  committee 
to  work  in  co-operation  with  a  state  instu-ance  commission  ap- 
pointed last  year  by  the  governor,  to  the  end  that  with  the 
aid  of  physicians  proper  legislation  might  be  constructed.  I 
use  that  word  constructed  advisedly  for  much  of  the  legislation 
with  which  we  are  afflicted  was  never  constructed,  it  just  hap- 
pened and  the  fact  that  it  just  happened  is  not  the  only  resem- 
blance it  bears  to  some  of  our  other  misfortunes.  Even  our 
legislators  as  well  as  our  physicians  seem  slow  to  learn  that  so- 
ciety is  readjusting  itself. 

Any  attempt  to  establish  such  social  insurance  as  will  secure  to  the  wage 
earner  and  his  family  protection  from  the  disastrous  efifects  of  sickness  pre- 
sents as  its  most  difficult  problem  any  form  of  adjustment  satisfactory  to 
the  medical  profession.  ^ 

The  British  Health  Instu-ance  Act  differs  decidedly  from  that  of  other 
European  countries  in  frankly  recognizing  this  difi&culty  by  way  of  a  com- 
promise between  the  interest  of  the  physician  and  the  interest  of  the  insured.* 

And  why  not  recognize  both  interests?  In  all  countries  insur- 
ance laws  are  formed  to  protect  not  only  the  insured  but  also 
safeguard  the  interest  of  the  insurer. 

Is  not  the  world  indebted  alone  to  the  medical  profession  for 
its  wonderful  progress  in  preventive  medicine?  And  is  there 
any  good  reason  either  in  logic  or  morals  why  the  progress  of  pre- 
ventive medicine  should  be  retarded  by  allowing  the  interests 
of  the  medical  profession  to  be  ignored  or  over-ridden?     The 

1  Rubinow. 

»  Rubinow,  Pamphlet,  p.  345. 


12 

Academy  would  do  well  to  urge  on  the  part  of  the  profession 
of  the  United  States  such  co-operative  consideration  of  these 
conflicting  interests  as  will  safeguard  the  future  progress  of  pre- 
ventive medicine. 

Social  instu-ance  has  not  yet  accomplished  its  mission.  It  is 
firmly  established  in  almost  every  European  country;  in  our 
American  commonwealth  it  has  just  begun  but  it  has  already 
made  of  the  questions  of  industrial  insurance,  health  insurance, 
insurance  against  unemployment,  the  relation  of  the  state  to 
mother  and  children,  definite  problems  that  demand  solution. 

While  the  great  movements  for  social  readjustment  have  swept 
society  like  a  mighty  cyclone,  the  medical  profession  has  had 
something  of  the  attitude  of  the  man  who  was  visiting  his  friend 
on  the  broad  prairies  of  Kansas  and  seeing  for  the  first  time  a 
tornado  he  inquired  of  his  friend,  "Say,  Jim,  you  have  had  some 
experience,  can  you  tell  me  how  I  can  stop  that  tornado?"  "Yes, 
we  have  had  some  experience  and  we  don't  stop  'em ;  we  find  we  are 
more  successful  to  just  go  with  them."  The  medical  profession 
not  only  of  the  United  States  but  throughout  the  world,  by  its 
open  opposition  to,  or  its  aloofness  from  this  movement  for  social 
insurance,  is  failing  to  render  to  humanity  that  service  which  is 
due  in  this  period  of  social  reconstruction. 

One  of  the  newest  and  most  interesting  phases  of  social  insur- 
ance is  that  which  touches  on  the  relationship  of  the  state  to 
motherhood  and  children. 

In  1 89 1  a  society  was  developed  in  France  known  as  the  Mutual- 
ite  Matemelle.  Although  formed  on  the  co-operative  plan,  its 
treasury  received  but  a  small  amount  from  its  members,  most 
of  the  funds  being  supplied  by  the  state  and  by  private  philan- 
thropies. Its  members  were  entitled  to  forty-eight  francs  at 
confinement  and  ten  francs  for  nursing.  This  society  was  so 
successful  that  it  stimulated  the  formation  of  many  similar  socie- 
ties throughout  Europe.  To-day  we  find  maternity  insurnace 
in  at  least  fourteen  countries  of  Europe.  These  are  all  or 
nearly  all  co-operative,  the  employer,  the  employee  and  the  state 
each  contributing  a  definite  proportion  to  a  common  fund. 


13 

Australia  and  France  have  a  system  of  maternity  insurance 
under  which  the  state  pays  all  the  benefits. 

The  British  laws  provide  for  a  benefit  at  confinement  for  the 
wives  of  all  insured  men  and  to  all  insured  women,  whether  mar- 
ried or  unmarried,  and  an  additional  sick  benefit  is  paid  to  all 
insured  women,  provided,  however,  they  are  married.  The 
British  laws  contain  another  very  remarkable  clause  which  states 
that  "Medical  benefit  shall  not  include  any  right  to  medical 
treatment  or  attendance  in  respect  to  a  confinement."  The 
British  medical  profession  stuely  was  not  in  evidence  when 
that  law  was  enacted. 

The  first  city  in  the  United  States  to  extend  definite  aid  to 
mothers  was  San  Francisco,  in  1908;  while  Missouri  must  be 
given  the  credit  for  enacting  the  first  mothers  state  pension 
law  in  191 1.  Since  then  mothers  pensions  laws  have  been  en- 
acted in  twenty-three  states.^  California,  Oregon,  Washington, 
Idaho,  Utah,  Nevada,  Arizona,  Colorado,  South  Dakota,  Minne- 
sota, Nebraska,  New  Hampshire,  Iowa,  Missoiu-i,  Wisconsin, 
Illinois,  Michigan,  Ohio,  Pennsylvania,  New  Jersey,  Massachu- 
setts, New  York  and  Tennessee. 

In  all  these  countries,  with  the  exception  of  Germany,  and  in 
all  American  states  as  far  as  I  can  learn  with  the  exception  of 
Colorado,  the  only  recognized  relationship  existing  between 
the  state  and  motherhood  and  children  is  poverty. 

Some  one  has  said  that  "The  first  test  of  eligibility  of  mothers 
to  state  recognition  is  poverty."  Is  it?  Or  is  it  motherhood? 
The  state  recognizes  poverty  as  poverty  and  relieves  it  in  every 
condition  of  life.  Whether  or  not  the  state  should  recognize 
and  foster  motherhood  on  the  quality  of  which  the  existence 
of  all  free  government  depends  is  a  question  which  will  be  discussed 
in  the  near  future. 

Italy  recognized  motherhood  and  not  poverty  as  the  first 
test  and  enacted  a  compulsory  maternity  insurance  law  in  19 10, 
although  she  has  no  health  insurance  laws.  This  maternity  law 
covers  only  working  women  who  are  employed ;  it  is  co-operation 
in  that  the  employer,  the  employee  and  the  state  each  contributes 

1  Mothers'  Pension,  p.  2. 


to  a  common  fund.  This  law  asks  not  whether  she  has  a  com- 
petence or  is  in  poverty.  The  fact  of  motherhood  alone  gives 
her  access  to  this  fund. 

Colorado  recognizes  motherhood  as  well  as  poverty  a  sufficient 
test  for  recognition.     The  Colorado  law  expressly  states  that:^ 

This  act  shall  be  liberally  construed  for  the  protection  of  the  child,  the 
home  and  the  state,  and  in  the  interest  of  public  morals,  and  for  the  preven- 
tion of  poverty  and  crime. 

In  commenting  on  this  law  Judge  Lindsey  says: 

It  is  a  recognition  by  the  state  that  the  aid  is  rendered,  not  as  a  charity, 
but  as  a  right  as  justice  due  mothers  whose  work  in  rearing  their  children 
is  a  work  for  the  state  as  much  as  that  of  the  soldier  who  is  paid  by  the  state 
for  his  services  on  the  battlefield;  it  is  a  recognition  for  the  first  time  by 
society  that  the  state  is  responsible  in  a  measure  for  the  plight  of  the  mother, 
and  acknowledges  its  responsibility  by  sharing  the  burdens  of  her  poverty 
that  is  created  largely  by  the  conditions  that  the  state  permits  to  exist. 

In  Colorado,  where  wife  and  child  desertion  is  growing  with  alarming 
rapidity,  the  deserters  are  generally  sent  to  a  very  comfortable  county  jail, 
where  they  are  fed  up,  and  the  wife  and  children  starve  outside.  The  detail 
as  to  the  payment  of  the  earnings  for  the  support  of  the  cases  mentioned  in 
the  act  was  intended  to  put  a  premium  on  motherhood  in  favor  of  the  women 
who  bear  children.  ^ 

The  state  owes  an  obligation  to  every  mother.  This  obliga- 
tion rests  not  on  the  chance  of  financial  rating  but  on  the  fact 
of  motherhood  and  the  state  recognition  of  this  obligation  should 
not  be  expressed  in  terms  of  charity,  which  it  is  not;  neither  as 
relief  of  poverty  which  is  humiliating,  but,  as  a  recognition  of 
motherhood  which  by  right  it  is. 

Germany,  which  at  the  outbreak  of  the  present  war  passed  an 
act  August  4,  19 14,  relieving  all  her  insurance  societies  of  their 
obligations  to  pay  maternity  insurance,  soon  found  it  was  in  the 
interest  of  public  policy  to  recognize  the  relation  of  motherhood 
to  the  Empire  in  a  very  tangible  manner,  and  only  fom*  months 
later,  December  2,  19 14,  she  re-enacted  a  maternity  benefit  law. 

This  law,  which  applied  only  to  soldiers  and  the  wives  of  insured 
men,  was  rapidly  modified  by  a  further  enactment  in  January, 
191 5,  and  again  in  April,  19 15,  by  which  its  maternity  benefits 

*  Judge  Lindsey  in  "Mothers'  Pensions,"  p.  23. 

*  Mothers'  "Compensation  Law  of  Colorado,"  Ben  B.  Lindsey,  Survey,  %9,  714-16. 


15 

were  made  to  include  women  in  domestic  service,  in  the  pursuit 
of  agriculture  and  in  other  occupations. 

Under  the  terms  of  this  law  each  mother  was  provided  for  both 
before  and  after  confinement;  she  w^as  given  free  treatment,  in- 
cluding medicines,  midwives,  physicians'  care,  and  the  child  is 
cared  for  till  it  is  fifteen  years  old.  Or  in  lieu  of  free  treatment 
and  care  the  mother  is  allowed  a  cash  benefit  to  the  amount  of 
133  marks  or  $31.65. 

In  this  decree,  as  pointed  out  by  Frankel,  "The  expression  of 
small  means"  (minderbemittelt)  is  employed  instead  of  "needy" 
or  "indigent"  (bedurftig)  in  order  that  the  aid  might  not  bear 
the  stamp  of  poor  relief.^ 

It  is  very  significant  that  this  law  eliminates  every  feature 
of  co-operative  contributions,  the  entire  expense  is  borne  by  the 
Empire. 

The  war  opened  Germany's  eye  to  the  dependence  of  the  state 
on  mothers  and  children,  for  she  says,  "The  enormous  sacrifice 
of  human  life  which  war  demands  makes  it  the  imperative  duty 
of  the  state  to  take  proper  care  for  the  preservation  and  strength- 
ening of  the  coming  generation  at  the  very  moment  of  entrance 
into  this  world." 

In  monarchial  governments  the  perpetuity  of  the  state  depends 
mainly  on  the  ability  of  the  ruler,  and  the  future  ruler  is  reared 
and  trained  for  the  purpose  of  ruling.  In  a  free  government 
the  children  are  the  future  rulers,  not  one  child,  but  the  majority 
of  children  are  rulers,  hence  the  relationship  of  the  state  to  parent- 
age is  quite  different  in  a  free  government  from  that  which  ob- 
tains under  a  monarchy. 

Stability  of  democratic  forms  of  government  depends  on  an 
intelligent  citizenry,  hence  the  duty  of  the  state  to  make  every 
citizen  intelligent,  not  only  to  give  them  the  opportunity  to  be- 
come intelligent  but  to  make  the  use  of  the  opportunity  compul- 
sory, hence  the  justice  of  our  compulsory  school  laws. 

Now  the  stability  of  the  state  depends  no  more  on  an  intelli- 
gent citizenry  than  does  the  perpetuity  of  the  state  depend  on  a 
vigorous   posterity    and   thru    a   vigorous    posterity    alone    can 

1  Frankel,  Maternity  Insurance,  p.  15. 


i6 

our  civilization  and  the  institutions  it  represents  be  preserved 
in  its  integrity  and  pass  unimpaired  to  the  control  of  those  who 
follow  us. 

I  wish  to  emphasize  this  duty  of  the  state  in  its  relationship 
to  motherhood  because  there  has  been  altogether  too  common 
a  feeling  that  the  state  should  concern  itself  only  with  the  more 
important  matters  of  tarriff  and  commerce  and  finance  and  not 
concern  itself  with  such  small  matters  as  motherhood.  It  is 
considered  as  an  unwarranted  meddling  in  domestic  affairs.  Of 
course,  it  is  all  right  to  appropriate  money  to  pay  the  cost  of 
maintaining  poor  houses  or  of  biuying  people  because  people 
just  have  to  be  buried,  but,  the  inference  is  that  people  don't 
just  have  to  be  bom,  at  least  if  they  do  it  doesn't  cost  anything. 
I  want  to  say  with  emphasis  that  there  are  few  questions  before 
the  American  people  which  so  vitally  effect  our  future  welfare 
as  the  problem  of  motherhood  and  children  and  the  recogni- 
tion of  the  obligation  of  the  state  to  foster  their  well-being.  And 
I  shall  recommend  that  these  problems  receive  careful  study  on 
the  part  of  the  Academy. 

Now  as  to  the  matter  of  jtu"isprudence.  Has  the  state  the 
right  to  recognize  any  obligation  or  relationship  between  the 
state  and  motherhood  and  children  except  the  duty  to  relieve 
poverty? 

The  right  of  the  state  to  legislate  in  behalf  of  the  health  of 
growing  children  by  forbidding  their  employment  at  hard  labor 
(during  the  early  years  of  their  growi:h)  and  to  restrict  the  hours 
of  labor  for  women  and  forbid  the  employment  of  mothers  for 
a  period  before  and  after  confinement  is  unquestioned.  All 
will  concede  that  the  state  has  the  right  to  enforce  such  legislation 
on  the  child  and  the  mother  whether  they  wish  it  or  not.  This 
is  a  plain  recognition  on  the  part  of  the  state  of  her  responsi- 
bility to  provide  for  the  physical  growth  and  well-being  of  her 
mothers  and  children  regardless  of  poverty. 

Almost  every  nation  of  Europe  has  by  law  protected  mothers 
from  labor  by  forbidding  their  employment  for  a  stated  time 
both  before  and  after  confinement.  Austria,  Holland,  Norway, 
Great  Britain  and  Germany  prohibit  work  for  two  weeks  before 


17 

and  four  weeks  after,  Italy  for  seven  weeks,  Belgium,  Portugal 
and  Spain  for  four  weeks,  Sweden  for  six  weeks. 

Laws  enforcing  a  period  of  rest  before  and  after  confinement 
have  been  enacted  in: 

Massachusetts,  enforced  rest  period  of  two  weeks  before  and 
four  weeks  after. 

Vermont,  enforced  rest  period  of  two  weeks  before  and  four 
weeks  after  confinement. 

Connecticut,  rest  four  weeks  before  and  four  weeks  after  con- 
finement. 

New  York  forbids  employment  of  women  for  four  weeks  after 
confinement. 

These  all  recognize  an  obligation  on  the  part  of  the  state  to 
care  for  both  mother  and  child,  a  relationship  not  based  on  pov- 
erty, but  on  the  physical  well-being  of  the  mother  and  child. 

In  any  comprehensive  study  of  the  relation  of  the  state  to  mother- 
hood will  be  involved  the  study  of  the  American  home  and  its 
preservation.  To-day  the  trend  of  society  is  decidedly  away 
from  the  home  idea;  women  are  no  longer  trained  in  the  idea 
that  the  development  of  a  happy  home,  around  the  fireside  of 
which  is  reared  a  group  of  healthy,  joyous  children,  is  infinitely 
the  greatest  achievement  within  the  range  of  her  possibilities. 
To-day  she  is  being  educated  to  compete  with  men  along  lines 
which  God  ordained  should  be  an  adjunct  of  fatherhood,  that  of 
providing  for  the  maintenance  of  the  family.  It  was  Timothy 
who  said  "He  (not  she)  that  provideth  not  for  his  own  and  espe- 
cially those  of  his  own  household  hath  denied  the  faith  and  is 
worse  than  an  infidel."^ 

I  am  a  believer  in  the  rights  of  women,  especially  the  right  of 
mothers  and  their  political  emancipation  and  while  I  quite  fully 
endorse  the  words  of  Dr.  Helen  C.  Putnam  that  **  Political  domi- 
nance of  sex  is  wholly  an  evil,  and  to  both  sexes;  that  the  only 
right  dominance  is  wisdom;  that  "law  made  by  men  not  based  on 
biologic  law  which  women  are  learning  ends  in  disaster.  "^  Yet 
among  men  and  women  who  are  thinking  deeply  on  social  prob- 

1  I  Tim.,  5  :  8. 

a  Bulletin  A.  A.  M.,  133,  p.  59. 


i8 

lems  there  is  a  well-founded  belief  that  this  tendency  away  from 
the  home  deas  bodes  no  good  to  the  future  stability  of  the  state 
and  that  there  is  no  question  more  vital  to  the  perpetuity  of  our 
civilization  than  the  fostering  of  all  those  interests  which  center 
in  the  American  home  and  make  possible  the  raising  of  better 
children.  There  is  no  real  home  except  that  which  clusters 
about  the  thought  of  mother  and  children,  yet  there  are  people 
who  honestly  question  whether  or  not  the  state  has  the  right  to 
aid  in  bettering  the  conditions  of  mothers  and  children.  But 
they  do  not  question  the  right  of  the  state  to  spend  large  sums  of 
money  to  better  the  conditions  of  some  other  things  that  cluster 
around  some  rural  homes  such  as  chickens  and  cows,  horses  and 
sheep,  pigs  and  potatoes.  No  one  questions  that  it  is  the  proper 
function  of  the  government  to  aid,  foster  and  improve  these  com- 
mercial factors  for  they  represent  money,  but  with  the  mother  and 
children  it  is  different.  The  preservation  of  dollars  as  the  chief 
function  of  government  must  yield  to  the  preservation  of  human 
beings.  Our  mad  scramble  for  the  elusive  dollar  so  permeates 
our  minds  that  we  are  like  the  Scotchman  who,  witnessing  the 
excavation  of  some  ancient  city,  saw  some  old  ruins  on  which  was 
a  placard  "Library  4000  B.  C,"  was  asked  by  a  friend  "What 
does  that  4000  B.  C.  mean"? 

"Hoot,  mon,  that  means  $4000  By  Carnegie." 

Let  us  see  if  the  home  idea  cannot  be  expressed  even  in  terms 
of  cash.  It  was  stated  in  the  report  of  the  public  health  service 
presented  last  month  at  the  tuberculosis  association  in  Washing- 
ton, D.  C,  that  "One-fourth  of  all  cases  of  tuberculosis  developed 
not  in  homes  but  in  lodging  houses,  where  men  are  deprived 
of  home  care."  That  means  an  annual  loss  of  25,000  lives  of  a 
monetary  value  of  $25,000,000. 

In  the  city  of  Cincinnati  the  average  monthly  income  of  19 17 
families  was  $57.00.  This  imposes  a  condition  under  which  the 
maintenance  of  a  home  or  the  raising  of  a  family  of  children  is 
difficult  or  impossible,  race  suicide  is  the  logical  solution.  From 
a  commercial  view-point  the  state  is  amply  justified  in  fostering 
the  home  idea. 

And  Dr.  Pratt  states  that  the  Emanuel  Church  of  Boston,  at 


19 

an  expense  of  $15,000,  increased  the  earning  capacity  of  tuber- 
culosis cases  $50,000. 

The  greatest  rival  of  our  American  home  is  modem  apart- 
ment houses  which  are  happily  eliminating  the  question  of  ser- 
vants but  they  are  also  eliminating  the  American  home  and 
the  most  substantial  class  of  American  babies,  for  all  applicants 
for  up-to-date  apartments  are  told  in  blunt  language  that  children 
are  not  wanted  and  among  our  most  valuable  class  of  people  when 
children  are  not  wanted  such  accidents  as  children  do  not  occur. 

I  believe  it  was  Joseph  Newton  who  said,  "The  hope  of  the 
world  is  in  the  child,  in  whose  dirty,  chubby,  candy-stained 
hands  lies  the  future  of  the  human  race.  In  him  we  live  again, 
if  in  no  other  way  in  memory  of  God  who  does  not  forget."  And 
some  one  else  has  said  that  "We  should  keep  that  man,"  be  he 
landlord  or  porter,  "Three  paces  distant  who  is  not  charmed 
with  the  beauty  of  flowers,  the  song  of  birds  and  the  prattle  of 
children." 

Viewing  this  question  from  the  standpoint  of  the  permanency 
of  free  government,  just  in  so  far  as  modern  apartment  houses 
can  induce  oiu:  better  class  of  citizens  to  select  them  as  a  place 
of  permanent  residence  and  yet  maintain  an  unwelcome  attitude 
toward  children,  thus  decreasing  the  flower  of  the  coming  genera- 
tion and  committing  to  an  inferior  people  the  maintenance  of 
our  democracy,  just  in  so  far  are  they  a  menace  to  free  gov- 
ernment. 

Any  place  where  children  are  unwelcome  is  not  a  fit  place  for 
married  Americans  to  establish  a  home,  however  heavenly  it 
would  be  for  the  solution  of  the  problem  of  the  feeble-minded. 

This  social  and  commercial  feeHng  against  children,  so  destruc- 
tive alike  to  broad  principle  of  service  to  humanity  and  the  future 
safety  of  our  democracy,  has  become  so  common  to-day  that  it 
is  almost  a  social  crime  to  raise  babies. 

This  fetish  of  fashionable  society  to  have  childless  homes,  like 
the  fetish  of  wealth  must  inevitably  pass.  The  time  was  when 
the  mere  possession  of  millions  was  a  social  passport  unques- 
tioned, society  next  demanded  of  the  possessor  of  millions,  how 
did  you  get  them?     Both  these  ideas  were  thrown  into  the  scrap 


20 

heap  of  a  passing  civilization  and  to-day  society  demands  of  the 
man  of  great  wealth,  what  are  you  doing  with  it?  So  likewise 
modem  democracy  is  demanding  of  every  social  selfish  jelly  fish 
that  they  be  transformed  into  dependable  human  beings  whose 
progeny  shall  develop  spinal  columns  stiff  enough  to  insure  the 
perpetuity  of  free  government. 

Our  national  success  and  national  permanence  depends  to  a 
very  large  degree  on  the  attitude  of  public  sentiment  toward  parent- 
age. The  hope  of  our  free  government  lies  not  in  her  standing 
army;  neither  great  leadership  nor  a  few  great  men;  for  genuine 
democracy  will  not  long  tolerate  great  leadership,  for  when  any 
man  rises  much  above  the  average  in  genuine  leadership  we 
Americans  demonstrate  our  personal  freedom  by  hitting  him 
on  the  head  suflGlciently  often  to  keep  him  much  closer  the  level 
of  the  average  man.  Without  hope  therefore  in  the  leadership 
of  great  men  our  only  hope  lies  in  eliminating  the  feeble  and 
raising  the  level  of  the  average.  This  again  emphasizes  the  vital 
relationship  of  the  state  to  motherhood  and  children,  for  so  sure 
as  our  citizenry  is  recruited  by  the  propagation  of  inferior  stock 
so  sure  will  our  democracy  terminate  in  total  disaster. 

The  fact  that  birth  rate  among  the  inferior  classes  is  relatively 
increasing  from  year  to  year  is  so  patent  to  all  that  it  is  super- 
fluous to  offer  proof  of  it. 

This  increase  of  our  population  from  inferior  stock  is  due  to 
several  factors: 

It  is  increasing  among  the  lowest  classes  because  of  a  lack  of  ap- 
preciation of  responsibility  and  the  ability  to  exist  on  very  small 
income. 

But  among  the  laboring  classes  of  the  better  grades  we  find 
very  many  mothers  who  cannot  afford  to  raise  babies  because 
their  incomes  are  not  sufi&cient  to  supply  what  they  consider 
the  necessaries  of  life. 

While  among  the  higher  classes,  who  are  the  most  pros- 
perous and  in  some  things  the  most  intelligent,  the  demands  of 
club  life  and  other  social  duties  so  obscure  that  larger  view  of 
life  that  real  patriotism  and  oiu-  obligations  to  humanity  are  lost 
sight  of. 


21 

Can  the  state  offer  any  remedy  to  this  condition?  Should  the 
state  in  any  manner  give  encouragement  to  the  raising  of  chil- 
dren? Why  not?  Is  it  not  the  duty  of  the  state  to  devise  a 
remedy  for  any  evil  that  threatens  its  permanency?  Then  why 
is  it  not  just  as  much  the  duty  of  the  state  to  reheve  the  wants 
of  a  mother  both  before  and  after  birth  of  the  child  and  while 
she  is  nursing  and  rearing  it  as  it  is  to  educate  that  same  child? 
Is  it  not  better  economy  to  educate  a  strong  and  healthy  child 
than  a  weakling?  And  recognizing  this  obligation  of  the  state, 
to  see  that  her  children  are  properly  cared  for,  make  the  raising 
of  children  a  greater  honor  to  her,  on  whom  the  state  is  depen- 
dent, and  thus  change  the  trend  of  public  sentiment  which  is  stead- 
ily making  headway  against  the  raising  of  children. 

How  much  has  the  state  ever  spent  to  foster  our  most  funda- 
mental bulwark,  the  American  home?  We  spend  a  large  sum  of 
money  each  year  (relatively  a  most  insignificant  pittance)  for 
the  care  of  children  in  institutions  where  initiative  is  crushed  in 
childhood  and  the  inspiration  for  doing  the  great  deeds  of  life 
are  never  fostered  by  the  reciprocal  love  of  father  or  mother, 
the  helpfulness  of  brother  or  sister,  the  inspiration  of  pets  and 
flowers,  of  childhood  freedom  and  childhood  conquests. 

Why  not  take  those  children  we  incarcerate  in  rule  ridden, 
motherless,  homeless  institutions  and  develop  them  at  the  same 
expense  or  at  any  reasonable  expense  in  good  homes,  where  chil- 
dren would  be  welcome  and  where  they  would  be  rounded  out 
into  men  and  women  with  an  experience  that  would  fit  them 
for  the  conflicts  and  the  conquests  of  after  life  and  fit  them  for  a 
better  fatherhood,  a  better  motherhood  and  a  better  home  builder? 

The  facts  presented  by  Judge  Pinckney  warrant  the  statement 
that  New  York  State  at  the  close  of  19 lo  was  caring  for  34,530 
children  in  institutions;  she  was  caring  for  ten-fold  as  many 
children  in  institutions  as  was  Illinois  with  only  two-fold  her 
population.^ 

Does  it  mean  that  the  social  influence  of  New  York's  "400*' 
has  made  homes  where  children  are  welcome  five  times  less  com- 
mon than  they  are  in  the  state  of  Illinois,  or  does  it  mean  that 

1  Child  1,  No.  5.  pp  43-50. 


22 

the  progressive  state  of  Illinois  has  been  doing  five  times  more 
child  thinking  and  home  thinking  than  has  New  York? 

Is  it  significant  that  in  191 1  Illinois  passed  a  state  wide  mother 
pension  law,  while  New  York  defeated  the  enactment  of  a  similar 
measure? 

If  the  state  owes  an  obligation  to  the  child  to  see  that  it  has 
food,  clothing  and  freedom  from  suffering,  then  it  should  restore 
as  far  as  possible  a  home  environment  and  a  mother's  love,  for 
every  child's  sense  of  justice  demands  this  right  to  a  mother's 
love  and  therefore  much  of  the  work  done  by  our  juvenile  court 
in  committing  children  from  the  care  of  a  home  to  the  care  of  a 
motherless  institution  is  wrong  and  much  of  our  so-called  charity 
and  philanthropy  is  hard-hearted  cruelty. 

It  was  a  wise  Rabbi  who  said  that  "God  could  not  be  in 
every  place,  therefore  he  made  mothers." 

The  following  from  Judge  Pinckney's  experience  will  illustrate 
my  thoughts : 

Meanwhile^  is  the  baby  of  a  widowed  mother  to  be  sent  to  a  foundlings' 
home,  the  twins  under  four  years  to  a  home-finding  society,  a  boy  of  six 
and  two  girls  of  eight  and  ten  years  to  a  training  school,  industrial  school, 
respectively?  And  then,  after  you  have  quietly,  but  firmly,  broken  up  the 
family  circle  and  distributed  the  little  ones  among  the  foiu"  institutions,  al- 
lotting to  each  the  proper  quota  in  accordance  with  the  age  rule,  there  still 
remains  the  mother.  What  of  her?  A  woman,  mentally,  morally  and  phys- 
ically sound,  the  victim  of  circumstances  and  conditions  for  which  society 
and  the  state  and  not  she  are  responsible,  too  great  a  burden  apparently  for 
organized  charity  to  care  for;  what  is  to  become  of  her?  Heartbroken, 
alone,  her  husband  dead,  her  children  widely  separated  not  only  from  her  but 
from  each  other,  weakened  physically,  mentally  and  morally  by  the  ruthless 
tearing  of  maternal  heart-strings,  where  will  her  footsteps  tend  to  lead  this 
pitiable  object  to  a  state's  ingratitude?  Will  she  survive  the  test  and  continue 
to  lead  the  honest  upright  life  or  will  she  drift  along  the  lines  of  least  resis- 
tance, ending  in  the  brothel  or  in  the  mad  house?  It  was  just  such  a  problem 
as  this  some  three  years  ago  that  first  challenged  my  attention. 

Such  cases  have  multiplied  since  then  and  have  made  me  realize  the  need 
of  this  new  law. 

The  picture  is  overdrawn,  say  you?  Words  cannot  express  a  child's  fear 
or  a  mother's  agony  at  such  a  time.  Watch  as  I  have  for  nearly  four  years, 
children  clinging  to  a  mother's  skirts  or  sobbing  in  a  mother's  arms;  see  the 
affrighted  look  on  the  mother's  face,  a  look  akin  to  that  seen  only  in  the  eyes 
of  a  dumb  animal  when  torn  from  her  young,  and  you  will  not  say  the  picture 
is  overdrawn,  and  you  will  come  to  believe  with  me  that  society  and  the 


23 

state  should  encourage,  cherish  and  not  destroy  this  most  sacred  thing  in 
human  life,  a  mother's  love,  and  should  guard,  protect  and  foster  the  grand- 
est institution  of  our  social  and  political  life,  the  home.^ 

Shall  the  state  in  any  manner  recognize  its  dependence  on  an 
intelligent  motherhood? 

Shall  the  state  give  any  encouragement  to  the  building  and 
preservation  of  our  American  homes? 

Shall  the  state  continue  to  destroy  that  which  is  best  in  her 
dependent  children  by  committing  them  to  institutions  or  shall 
she  rear  them  to  patriotic  citizenship  under  the  influence  of  home 
environment  and  the  love  of  even  foster  parentage  ? 

What  should  the  state  do  to  foster  good  motherhood? 

What  is  the  state  paying  annually  for  bad  motherhood?  These 
are  problems  worthy  of  our  best  thought. 

You  ask  what  have  I  to  offer  by  way  of  solution.  It  is  my 
purpose  to-night  to  present  to  you  some  facts  and  ask  if  in  your 
judgment  they  do  not  constitute  a  problem  worthy  of  solution. 
If  they  do,  as  I  firmly  believe,  then  the  solution  should  be  worked 
out  by  a  careful  study  of  their  many  details.  We  have  altogether 
too  much  law  making  and  too  little  law  thinking. 

There  is  no  greater  service  the  Academy  can  render  to  both 
the  medical  profession  and  to  society  than  a  constructive  solu- 
tion of  the  present  polyhedral  question  of  social  insurance  and 
the  relation  of  the  state  to  motherhood  and  children.  The  rapid 
development  of  these  questions  constitute  one  of  those  great  tidal 
waves  of  society  against  which  opposition  is  futile.  The  only  way  to 
meet  it  is  by  an  intelligent  solution.    For  this  solution  I  recommend : 

That  a  committee  be  appointed  to  be  known  as  the  Social 
Insurance  Committee  whose  duty  it  shall  be  to  make  a  special 
study  of  the  whole  problem  of  social  insurance  and  the  relation- 
ship of  the  state  to  motherhood  and  children,  for  the  purpose  of 
enabling  the  Academy  to  render  such  aid  in  the  final  adjustment 
of  these  problems  as  will  best  conserve  the  interest  of  the  state, 
the  demand  of  society,  the  interests  of  medical  profession,  and 
the  needs  of  the  individual. 

I  recommend  that  the  report  of  this  committee  be  given  in 
the  form  of  a  symposium  for  the  meeting  of  19 18. 

1  Mothers'  Pensions,  p.  142-143. 


LEGISLATION  REGULATING  THE  PRACTICEOF  MEDI- 
CINE, PRELIMINARY  AND  MEDICAL   EDUCA- 
TION. 

By  N.  P.  CotwELL,  M.D.,  Chicago,  111.,  Secretary  of  the  Council  on  Medical  Education 
of  the  American  Medical  Association. 

INTRODUCTORY. 

On  this  important  topic  it  is  difficult  to  present  anything  new 
to  this  audience  composed,  as  it  is,  of  those  who  are  famiUar 
with  the  conditions  underlying  medical  education  and  licensure. 
The  only  hope,  therefore,  is  to  present  the  already  familiar  facts 
in  such  manner  as  to  emphasize  those  which  are  most  important, 
and  possibly  to  enable  you  to  view  them  from  a  new  standpoint. 

Minimum  Qualifications  Necessary  to  Guarantee  Competency  on 
the  Part  of  Those  Who  Are  to  Treat  the  Sick, 

All  in  this  audience  are  doubtless  familiar  with  the  phenomenal 
changes  which  have  been  made  in  medical  education  during  the 
last  ten  or  twelve  years.  Instead  of  162  medical  colleges  in  the 
United  States,  only  four  or  five  of  which  held  entrance  require- 
ments of  one  or  more  years  of  college  work,  we  now  have  95 
medical  colleges,  83  of  which  hold  the  higher  entrance  standard. 
In  brief,  quantity  has  given  way — largely  through  the  merging 
process — to  quality;  an  abnormal  supply,  mostly  of  poorly 
equipped,  low-standard  institutions,  has  given  way  to  a  more 
normal  supply  of  higher  standard  and  better  equipped  medical 
schools.  But  this  amazing  change  does  not  seem  so  remarkable 
when  one  considers  the  two  distinct  processes  which  have  been 
at  work  during  the  previous  thirty  or  forty  years. 

Following  the  Civil  War,  with  the  rapid  settlement  of  the 
central  and  western  parts  of  the  country,  there  was  an  unusual 
but  actual  demand  for  physicians,  and  the  teaching  of  medicine 
became  a  profitable  business.  This  was  the  stimulus  which 
led  to  the  rapid  increase  in  the  number  of  medical  colleges  which 
gave  this  country  over  half  of  the  world's  supply.  Because  of 
the  profits,  however,  this  increase  continued  long  after  the  real 


25 

demand  for  physicians  had  been  satisfied.  But  during  the  same 
period  the  very  forces  were  also  at  work  which  were  eventually 
to  demand  an  entirely  different  type  of  medical  school.  Prior 
to  that  period  medical  knowledge  consisted  largely  of  clinical 
observations  and  theories  based  on  them,  but  during  the  last 
three  decades  of  the  nineteenth  century  there  was  an  increase 
of  medical  knowledge  unprecedented  in  the  history  of  medicine. 
At  the  beginning  of  that  period  Virchow  estabHshed  his  system 
of  cellular  pathology  and  demonstrated  the  cellular  origin  of  dis- 
ease. It  was  dtuing  that  period  that  Louis  Pasteiu'  demonstrated 
positively  the  r61e  played  by  bacteria  in  natural  processes  such 
as  fermentation,  decay  and  putrefaction.  Pastetur's  researches 
marked  the  beginning  of  bacteriology,  which,  in  tiurn,  has  revo- 
lutionized the  practice  of  medicine.  Pasteur's  work  was  followed 
in  1876  by  Koch's  researches  in  regard  to  anthrax,  and  in  1882 
Koch's  invention  of  solid  culture  media  and  methods  for  the  isola- 
tion of  single  species  of  bacteria.  You  all  know  how,  from  that 
time  on,  discoveries  of  the  germ  origin  of  numerous  diseases 
were  made  in  rapid  succession,  so  that  within  a  few  years'  time 
the  specific  origin  of  many  of  the  common  diseases  was  positively 
known.  Not  only  were  positive  methods  made  available  for 
their  diagnosis  and  treatment,  but  also  the  spread  of  each  disease 
has  been  prevented  and  numerous  immunizing  or  opposing  sub- 
stances, in  the  form  of  vaccines  and  antitoxins,  were  discovered. 
The  researches  of  Pasteur  and  the  discoveries  since  his  time 
practically  revolutionized  the  conception  of  disease.  The  old 
ideas  of  etiology  of  diseases  gave  way  to  an  absolute  knowledge 
regarding  their  bacterial  origin,  and  the  old  empirical  methods 
of  treatment  gave  way  to  more  scientific  methods — methods 
based  on  a  study  of  the  habits  of  the  specific  germ  causing  each 
disease.  The  victories  of  medical  research  have  emphasized  the 
importance  of  an  adequate  training  for  those  who  are  to  care  for 
the  sick.  They  have  emphasized  the  importance  also,  not  only 
of  the  premedical  sciences — ^physics,  chemistry  and  biology — 
but  also  of  the  fundamental  medical  sciences — anatomy,  phys- 
iology, physiological  chemistry,  pharmacology,  bacteriology  and 
pathology.    The  advances  have  demonstrated  how  firmly  mod- 


26 

em  medicine  is  based  on  these  sciences  and  how  decidedly  il- 
logical and  unscientific  is  any  system  of  healing  which  is  not 
based  on  them.  A  medical  college  is  no  longer  able  to  furnish 
a  satisfactory  training  unless  it  possesses  thoroughly  equipped 
laboratories  in  these  fundamental  sciences.  Nor  can  these  sciences 
be  taught — as  they  formerly  were — by  busy  practitioners,  who 
gave  only  their  spare  time  to  teaching.  These  sciences  must 
now  be  taught  by  salaried  experts  who  devote  their  entire  time 
to  teaching  and  to  research. 

Again,  a  grammar  school  education  no  longer  constitutes  an 
adequate  preliminary  training  for  those  who  are  to  study  medi- 
cine. The  student  needs  a  knowledge  of  physics,  of  chemistry 
and  of  biology,  in  order  to  better  understand  the  more  complex 
medical  sciences.  He  needs  to  study  anatomy  and  pathology  so 
he  may  differentiate  between  normal  and  abnormal  structures 
and  conditions  and  note  the  changes  produced  by  disease;  he  must 
study  bacteriology  so  as  to  understand  the  diseases  caused  by 
such  micro-organisms;  he  needs  physiology  and  physiological 
chemistry  so  he  may  understand  the  function  and  composition 
of  the  various  secretions  and  substances  of  the  body;  he  must 
study  pharmacology  so  he  can  note  the  physiological  action  of 
various  chemical  and  medicinal  substances;  he  needs  to  study 
the  various  types  of  disease  in  dispensaries  and  at  the  bedside 
in  hospitals,  and  while  still  under  supervision  he  should  further 
develop  skill  and  reliability  and  round  out  his  course  of  medical 
training  by  at  least  a  year's  experience  as  an  intern, 
or  resident  physician,  in  a  good  hospital.  A  student  who  has 
followed  this  routine  course  will  usually  be  a  safe,  efficient  and 
successful  practitioner  of  medicine.  If  he  desires  to  specialize 
in  any  particular  class  of  disease  or  in  any  particular  method 
of  treatment,  the  course  thus  outlined  should  be  followed  by  one 
or  two  years  of  study  devoted  to  the  desired  specialty. 

The  educational  standard  now  enforced  in  all  leading  nations, 
and  which  should  be  adopted  in  every  state  in  this  country,  as 
the  reasonable  minimum  requirement  for  those  who  are  to  treat 
the  sick,  includes: 

(a)  A  secondary  school  education  equal  to  that  obtained  in  an 


27 

accredited  four-year  high  school  and  in  addition  two  years  of 
work  in  an  approved  college  of  liberal  arts,  including  courses 
with  laboratory  work  in  physics,  chemistry  and  biology  of  at 
least  eight  semester  hours  each.  (Educationally,  the  quantity 
and  quality  of  the  work  in  these  two  years  should  be  no  whit 
less  than  that  required  in  the  first  two  years  for  the  Bachelor  of 
Science  degree.) 

(5)  A  medical  training  provided  by  a  four-year  course  in  a 
well-equipped  medical  college,  including  two  years  of  laboratory 
work  in  anatomy,  physiology,  physiological  chemistry,  pharma- 
cology, bacteriology  and  pathology,  and  two  years  of  clinical 
instruction  in  dispensaries  and  hospitals,  and 

(c)  The  practical  experience  obtained  in  a  fifth  year  as  an  in- 
tern in  a  good  hospital. 

In  brief,  anyone  who  is  to  undertake  the  repair  of  delicate 
life  processes  of  human  beings,  which  are  rendered  doubly  sensi- 
tive in  times  of  sickness,  should  have  had  such  a  training  as  will 
enable  him  to  differentiate  between  normal  and  abnormal  condi- 
tions and  to  determine  what  particular  disorder  is  present;  to 
be  acquainted  with  all  the  approved  methods  of  treatment  so 
as  to  apply  the  particular  treatment  which  will  best  meet  the 
needs  of  the  patient.  To  safeguard  the  interests  of  the  public, 
no  educational  training  less  than  this  should  be  countenanced 
in  any  state,  and  the  legal  provision  for  the  strict  enforcement 
of  such  a  requirement  should  be  provided.  No  other  department 
of  education  needs  to  be  so  strictly  supervised  as  medicine,  since 
in  no  other  calling  does  the  practitioner  assume  the  responsibility 
for  the  lives  of  human  beings  and  in  no  other  profession  can  bun- 
gling or  ignorance  work  such  havoc.  The  failure  of  any  state 
to  assume  responsibility  in  these  matters  is  shown  to  be  all  the 
more  serious  since  the  discoveries  following  Pasteur's  work  have 
added  so  much  to  the  positive  knowledge  by  which  diseases  and 
epidemics  may  be  prevented  or  eradicated. 

State  Control  of  Physician's  Educational  Qualifications — Medical 

Licensure. 

A  legal  provision  for  the  licensing  of  those  who  are^  to  treat 
the  sick,  therefore,  is  a  matter  of  vital  importance  to  the  public. 


28 

Such  provision  is  necessary  to  protect  the  public  against  those 
who,  for  educational,  mental,  moral  or  other  reasons,  are  unfit 
to  be  entrusted  with  the  lives  of  sick  human  beings.  On  the 
other  hand,  a  license  granted  by  legal  authority  to  anyone  who 
assumes  the  r61e  of  the  physician  should  be  a  guaranty — and  the 
public  have  the  right  to  so  look  upon  it — that  the  holder  is  a  safe 
and  competent  person  to  furnish  medical  care  in  times  of  sick- 
ness or  injury.  As  to  the  responsibility  for  the  licensing  of  physi- 
cians, much  has  been  said  in  recent  years  in  regard  to  the  police 
power  of  the  individual  state  as  the  only  source  of  authority 
for  the  control  of  medical  licensure.  The  statement  has  also 
been  frequently  made  that  this  agreement  is  provided  for  by  the 
Constitution  of  the  United  States.  A  noted  student  of  that  docu- 
ment, however,  states  that  the  Constitution  is  entirely  silent  on 
the  subject.  Sufi&cient  be  it  to  say,  that  instead  of  being  con- 
trolled by  the  national  government,  as  is  the  case  in  most  other 
countries,  the  responsibility  for  the  licensing  of  physicians  has 
been  left  with  the  fifty  individual  states.  This  responsibility 
has  been  fully  assumed  and  excellent  measures  adopted  in  some 
states ;  in  others,  the  seriousness  of  the  responsibility  has  not  been 
recognized,  and  in  those  of  a  third  group  so  many  conflicting 
laws  have  been  adopted,  or  so  many  different  boards  and  stand- 
ards provided,  as  to  make  a  ridiculous  botch  of  the  whole  affair. 
In  the  majority  of  states  the  matter  is  too  closely  interwoven 
with  politics  to  permit  the  adoption  of  the  most  efficient  control. 
In  the  fifty  states  there  are  now  fifty  different  medical  practice 
acts,  providing  for  sixty-two  separate  and  independent  boards, 
no  two  of  which  entirely  agree  in  the  details  of  the  methods  fol- 
lowed or  of  the  standards  enforced.  Even  in  the  individual 
states  there  is  not  always  a  single  authority  over  these  matters. 
In  some  states  the  authority  is  divided  between  two  or  three  en- 
tirely separate  and  independent  boards. 

Instead  of  a  single  simple  and  efficient  authority  vested  in  a 
national  body,  as  found  in  other  countries,  therefore,  the  regula- 
tion of  the  practice  of  medicine  in  the  United  States,  from  a  na- 
tional point  of  view,  is  most  confusing,  complex  and,  as  a  result, 
ineffective.     There  is  no  legal  provision  for  uniformity  or  action, 


29 

or  for  cooperation  between  these  boards.  We  have  every  grade 
of  standard,  from  the  few  states  in  which  educational  require- 
ments are  reasonably  high  and  well  administered,  down  to  the 
states  which  still  do  not  provide  for  or  do  not  enforce  any  stand- 
ards. While  in  a  state  having  an  adequate  and  effective  control 
of  these  matters  a  seriously  incompetent  applicant  may  be  re- 
jected, he  promptly  goes  to  another  state — perhaps  merely  cross- 
ing a  state  line — ^where  he  seldom  fails  to  obtain  a  license.  Should 
he  happen  to  fail  in  the  second  state,  he  goes  to  a  third,  or  to  a 
fourth — he  has  fifty  chances!  In  any  other  country,  after  one 
careful  investigation  of  his  credentials  or  after  one  examination, 
such  an  applicant  would  have  to  obtain  further  medical  training 
and  show  adequate  qualifications  or  he  could  not  obtain  the  legal 
right  to  treat  the  sick  an3n\^here  or  by  any  method. 

Since  there  is  no  national  control  of  medical  education  and 
licensure,  there  is  all  the  more  reason  why  an  effective  control 
should  be  established  in  each  state.  To  prevent  confusion 
there  should  be  but  one  body  or  board  in  each  state,  made  up  of 
the  most  competent  physicians  available.  This  board  should  be 
given  full  authority  to  license  all  those  who  are  to  treat  the  sick. 
It  should  be  given  power  to  prescribe  and  enforce  reasonable 
standards  of  preliminary  and  medical  education,  as  well  as  to 
verify  and  test  the  qualifications  of  every  candidate  seeking  a 
license  to  practice.  The  best  guarantee  of  satisfactory  qualifica- 
tions comes  through  the  duplex  requirement  of  (a)  graduation 
from  a  reputable  medical  college,  and  (b)  the  passing  of  an  examina- 
tion. Where  the  board  can  refuse  to  admit  to  its  examinations 
all  but  those  who  have  graduated  from  high-grade  medical  schools, 
then  the  public  will  have  fairly  adequate  protection  against  un- 
trained and  incompetent  physicians,  even  if  the  examination  is 
not  made  long  and  severe.  But  where  the  board  is  limited  to 
an  examination  as  the  only  means  of  determining  an  applicant's 
qualifications,  then  indeed  that  examination  should  be  especially 
thorough  and  comprehensive  and  should  include  practical  labora- 
tory and  clinical  tests.  Otherwise  the  examination  could  be  passed 
after  a  few  weeks  in  a  quiz  class,  by  those  who  may  never  have 
performed  or  witnessed  an  experiment  in  the  laboratory,  who 


30 


may  never  have  attended  a  clinic,  or  who  may  never  have  ex- 
amined a  patient  in  a  dispensary  or  hospital. 
Preliminary  Education. 
There  are  now  sixteen  states  in  which  the  boards  have  definitely 
adopted  as  a  minimum  standard  of  preliminary  education,  in 
addition  to  a  four-year  high  school  course,  two  years  of  collegiate 
work.  These  states  and  the  years  when  the  requirement  affects 
all  applicants  are: 

Minnesota 1912 

New  Hampshire,    191 9 

New  Mexico. ...    1922 

New  Jersey 192 1 

North  Dakota..  .    191 2 


Oklahoma 1921 

South  Dakota. . .  19 15 

Virginia 192 1 

Washington 1922 

Wisconsin 1919 


Alabama 1919 

Arizona 1922 

Colorado 1914 

Indiana 1915 

Iowa 1915 

Maryland 1922 

In  four  of  these  states — Arizona,  Maryland,  New  Mexico 
and  Washington— the  increased  requirement  is  automatic,  since 
the  practice  act  calls  for  the  standards  of  the  Association  of  Amer- 
ican Medical  Colleges  and  that  Association  has  adopted  the  higher 
requirement.  Under  the  Association's  standard  these  states 
now  require  a  four-year  high  school  education;  in  19 18  they  will 
require,  in  addition  to  the  high  school  course,  one  year  of  college 
work,  and  in  1922  two  years  of  college  work  will  be  required. 
The  medical  practice  act  of  Nevada  also  provides  that  the  stand- 
ards of  the  state  shall  be  those  of  the  Association  of  American 
Medical  Colleges.  The  Attorney-General  of  Nevada  is  said  to 
have  decided,  however,  that  the  standard  in  the  state  is  not 
automatically  raised  by  changes  made  by  the  Association  of  Amer- 
ican Medical  Colleges.  The  opposite  view  has  been  taken  by 
all  the  other  states  named. 

There  are  seventeen  states  in  which  the  boards  have  adopted 
the  requirement  of  one  year  of  collegiate  work  in  addition  to 
the  high  school  education.  These  states  and  the  years  when  the 
requirement  affects  all  applications  are: 

Arkansas 1919         Louisiana 1919 

CaHfomia 1919         Michigan 1918 

Mississippi. .....  1919 

North  Carolina . .  1 9 1 8 

Pennsylvania....  191 8 

Rhode  Island —  19 18 


Connecticut 19 14 

Illinois 1919 

Kansas 1914 

Kentucky 1918 


Tennessee 1919 

Texas 1918 

Utah 1 91 7 

Vermont 1917 

West  Virginia.  .  .  1921 


Maine 

Nevada 

Missouri 

New  York 

Nebraska 

Ohio 

31 

The  higher  requirement  has  been  adopted  by  the  regular 
board  in  Arkansas  and  Louisiana.  There  is  nothing  to  indicate 
that  their  example  has  been  followed  by  the  other  boards  in 
those  states. 

There  are  nine  states  in  which  a  standard  four-year  high  school 
course  is  the  minimum  standard  of  preliminary  education.  These 
states  are: 

Delaware 

Florida 

Georgia 

The  standard  has  been  adopted  by  the  regular  board  of  Florida, 
but  evidently  not  by  the  eclectic  and  homeopathic  boards. 

In  one  state,  Montana,  the  board  appears  to  have  the  authority 
to  adopt  a  standard  of  preliminary  education,  but  as  yet  has  not 
done  so. 

In  five  states  the  authority  is  too  limited,  or  there  are  two 
or  three  independent  licensing  boards,  some  of  which  evidently 
have  not  established  standards  of  preliminary  education,  or  the 
standard  is  less  than  a  four-year  high  school  education.  These 
states  are: 

Arkansas  Idaho  South  Carolina 

Florida  Louisiana 

There  are  now  only  three  states — District  of  Columl)ia,  Massa- 
chusetts and  Wyoming — in  which  the  practice  acts  do  not  pro- 
vide for  preliminary  education. 

Authority  to  Determine  Reputability  of  Medical  Colleges. 
There  are  now  forty -four  states  in  which  the  applicants  are  re- 
quired to  be  graduates  of  "reputable  medical  colleges"  as  deter- 
mined by  the  board.  This  gives  the  boards  of  those  states  the 
authority  not  only  to  fix  educational  standards  but  also  to  refuse 
to  recognize  medical  colleges  which  do  not  adhere  to  these  stand- 
ards, or  which  are  lacking  in  teachers  or  equipment.  In  some 
states  recognized  colleges  are  referred  to  as  "in  good  standing," 
in  others  they  are  considered  as  "reputable,"  and  elsewhere 
they  are  "registered,"  while  in  other  states,  as  in  Michigan, 
they  are  divided  into  groups,  only  those  of  the  first  group  having 


32 

full  recognition.  Of  the  forty-four  states  having  this  authority, 
thirty  are  making  more  or  less  use  of  it,  each  having  ceased  to 
recognize  from  three  to  thirty  colleges.     These  states  are: 


Alabama^ 

Minnesota  1 

Oklahoma! 

Colorado  1 

Mississippi 

Pennsylvania 

Delaware 

Missouri 

Rhode  Island 

Georgia 

New  Hampshire  1 

South  Carolina 

Illinois 

New  Jersey  1 

South  Dakota^ 

Indiana  1 

New  Mexico 

Texas 

lowa^ 

New  York 

Vermont 

Kentucky- 

North  Carolina 

Virginia^ 

Maine 

North  Dakotai 

West  Virginia 

Michigan 

Ohio 

Wisconsin  1 

In  five  states  the  authority  to  refuse  recognition  to  inferior 
medical  schools  rests  with  two  or  three  separate  boards,  but  so 
far  as  indications  show,  only  one  board — the  regular — is  making 
use  of  that  authority.  These  states,  and  the  number  of  separate 
boards  in  each,  are: 


Arkansas,  3 
Connecticut,  3 


Florida,  3 
Louisiana,  2 


Maryland,  2 


The  confusion  from  the  division  of  authority  has  repeatedly 
resulted  in  a  practical  annulment  of  educational  standards. 
As  an  example,  an  inferior  medical  college  in  Kansas  City,  which 
is  not  recognized  in  Missouri  or  in  thirty-three  other  states, 
has  for  several  years  been  sending  most  of  its  graduates  to  the 
Eclectic  Board  of  Arkansas,  where  there  is  seldom  a  failure  to 
pass. 

In  nine  states  the  boards  are  evidently  not  making  use  of  the 
authority  given  them  to  refuse  recognition  to  inferior  medical 
colleges.     These  states  are: 


Arizona 

Montana 

Oregon 

California 

Nebraska 

Tennessee 

Kansas 

Nevada 

Washington 

In  Tennessee  the  power  not  only  to  fix  standards  of  preliminary 
education  but  also  to  determine  what  medical  colleges  are  "reputa- 

1  These  twelve  states  will  not  accept  a  diploma  from  any  college  unless  the  holder  of 
it,  in  addition  to  a  four-year  high  school  education,  completed  two  years  of  college  work 
before  entering  on  the  study  of  medicine. 


33 

ble"  rests  with  the  recently  estabhshed  Board  of  Preliminary 
Examiners.  This  board,  however,  has  not  as  yet  established  a 
list  of  recognized  medical  schools. 

In  five  states  the  practice  acts  do  not  give  the  boards  the  author- 
ity to  insist  on  any  standard  of  medical  education,  but  they  must 
admit  to  their  examinations  the  graduate  of  any  legally  char- 
tered "medical  college,"  no  matter  how  low  its  entrance  qualifica- 
tions, or  how  lacking  it  may  be  in  teachers,  laboratories  or  clin- 
ical material.     These  states  are: 

District  of  Columbia        Massachusetts  Wyoming 

Idaho  Utah 

There  are  fourteen  states  in  the  last  two  groups,  therefore,  in 
which  all  applicants  are  admitted  to  examinations,  regardless 
of  the  character  of  the  college  from  which  they  obtained  their 
credentials.  And  in  no  one  of  them  does  the  examination  re- 
quired for  the  license  compare  in  severity  with  those  required 
in  England  and  in  the  various  countries  of  Europe.  Further- 
more, since  the  graduates  of  thirty-one  medical  schools  are  no 
longer  admitted  to  examinations  in  from  13  to  35  states,  those 
graduates  will  pour  into  the  states  which  continue  to  admit  them. 
These  fourteen  states,  therefore,  will  literally  become  the  "dump- 
ing ground"  for  those  candidates  who  are  not  considered  accepta- 
ble elsewhere  and  the  examinations  as  held  at  present  are  scarcely 
such  as  will  prevent  their  obtaining  the  right  to  practise. 

Recognition  of  Foreign  Credentials. 

It  has  not  been  many  years  since  credentials  from  almost 
any  foreign  medical  college  were  more  worthy  of  consideration 
by  state  licensing  boards  than  those  from  the  average  medical 
college  in  this  country.  That  was  true  when  less  than  ten  (less 
than  5  per  cent,  of  aU)  medical  schools  in  the  United  States,  in 
admission  requirements  and  in  teachers  and  equipment,  were  on  a 
par  with  the  medical  colleges  of  Europe.  Now,  however,  there 
are  at  least  60  (or  over  60  per  cent,  of  all)  medical  colleges  in  this 
country  which  can  stand  the  comparison.  The  time  has  come, 
therefore,  when  more  care  should  be  exercised  by  state  boards 
in  the  verification  and  evaluation  of  credentials  from  abroad  and 


34 

only  those  of  unquestioned  excellence  should  be  accepted.  It 
appears  that  some  state  boards  are  still  unusually  generous  in 
recognizing  such  credentials,  even  when  they  come  from  medical 
schools,  the  very  existence  of  which  is  doubtful. 

Interstate  Reciprocity  in  Medical  Licensure. 

Candidates  are  frequently  registered  without  examination  on 
presentation  of  satisfactory  credentials,  which  include  the  license 
issued  by  some  other  state.  This  method  of  registration  is  com- 
monly referred  to  as  "reciprocity,"  which  conveys  the  idea  that 
the  state  which  accepts  the  license  of  one  state  will  in  return 
be  granted  the  same  courtesy  by  that  state.  The  term  does  not 
always  apply,  however,  since  some  boards — ^for  example,  Cali- 
fornia and  Colorado — accept  the  physician's  credentials  if  satis- 
factory, no  matter  whether  the  state  board  issuing  the  original 
license  returns  the  favor  or  not. 

The  arrangement  for  reciprocity  is  a  matter  of  justice  to  physi- 
cians previously  licensed  in  some  other  state  who,  perhaps,  for 
many  years  have  been  engaged  in  the  reputable  practice  of  their 
profession  but  who  for  good  reason  desire  to  move  to  other 
states.  As  usually  administered,  however,  reciprocal  relations 
tend  to  lower  rather  than  to  elevate  educational  standards.  Such 
relations  exist  in  numerous  instances  between  states  having  not 
only  decidedly  unequal  standards  of  preliminary  and  medical 
education,  but  also  decidedly  unequal  methods  of  examination. 
It  is  clear,  therefore,  that  no  candidate  coming  from  the  state 
having  a  lower  educational  standard  should  be  accepted  by  the 
other  state  unless,  in  addition  to  this  license,  he  holds  educa- 
tional qualifications  which  meet  the  requirements  of  the  other 
state.  It  can  be  seen,  therefore,  that  a  loose  administration  of 
registration  through  reciprocity  would  provide  an  open  door 
for  numerous  unqualified  candidates.  It  is  evident  that  every 
board  should  reserve  and  exercise  the  right  to  reject  any  candi- 
date who  does  not  possess  satisfactory  credentials,  even  though 
he  is  registered  in  some  state  with  which  it  has  reciprocal  rela- 
tions. 

Again,  a  board  should  require  that  the  applicant,  before  he  is 


35 

eligible  for  reciprocal  registration,  should  have  been  in  the  actual 
and  reputable  practice  of  his  profession  for  at  least  a  year  in  the 
state  in  which  the  original  license  is  granted.  Without  this  pro- 
vision a  candidate  may  be  tempted  to  obtain  his  original  license 
in  the  state  giving  the  easiest  examination.  Naturally,  a  state 
should  retain  the  right  to  refuse  to  register  by  reciprocity  candi- 
dates who  have  failed  to  pass  their  own  examinations. 

At  present  forty  states  have  established  reciprocal  relations 
with  from  one  to  thirty-two  other  states.  The  nine  states  which 
do  not  reciprocate  with  others  are: 


Alabama 

Florida 

Oregon 

Arizona 

Massachusetts 

Rhode  Island 

Connecticut 

Montana 

Washington 

Progress  in  Medical  Licensure. 

Information  shows  that  until  about  forty  years  ago  only  one 
or  two  states  had  secured  laws  regulating  the  practice  of  medi- 
cine and  that  until  after  1900  very  few  had  adopted  definite 
requirem^ents  either  in  regard  to  preliminary  or  medical  educa- 
tion. It  was  when  the  supply  of  medical  colleges  had  reached  such 
amazing  proportions,  and  the  securing  of  a  diploma  had  become 
such  an  easy  matter,  that  the  necessity  for  licensing  boards  was 
recognized.  That  diplomas  had  come  to  have  a  questionable 
value  as  a  qualification  for  the  license  is  evidenced  by  the  fact  that 
the  first  requirement  given  general  adoption  by  the  majority  of 
boards  was  that  of  an  examination.  All  states  but  one — New 
Mexico — have  adopted  that  requirement  for  every  candidate, 
and  the  action  in  all  states  was  taken  during  the  twenty-five 
years  betw^een  1882  and  1907.  In  the  recent  campaign  for  an 
improved  medical  education  the  changes  in  medical  colleges 
were  more  rapid  than  those  by  state  boards.  This  was  to  be  ex- 
pected, since  the  obtaining  of  improved  legislation  was  neces- 
sarily a  slow  process.  Within  the  last  few  years,  however,  the 
changes  for  the  better  by  state  boards,  and  particularly  the  adop- 
tion of  improved  standards  of  preliminary  education,  have  been 
so  remarkable  as  to  parallel  the  advances  made  by  medical  col- 
leges.    It  is  noteworthy  that  the  improved  standards  of  prelim- 


36 

inary  education  came  largely  as  a  voluntary  movement  on  the 
part  of  medical  colleges,  since  their  adoption  of  the  higher  stand- 
ards preceded  the  action  taken  by  state  boards.  Nevertheless, 
these  boards  are  now  supporting  the  better  class  of  medical  col- 
leges, which  make  it  certain  that  reasonable  standards  of  pre- 
liminary and  medical  education  are  to  prevail  in  the  United  States. 
This  action  by  the  state  boards,  furthermore,  induced  other  col- 
leges to  adopt  the  higher  standards  which  for  financial  or  other 
reasons  were  not  willing  to  do  so  voluntarily.  Only  a  few  more 
states  need  to  secure  legislation  providing  for  better  educational 
standards.  Then — and  the  time  is  not  far  distant — all  medical 
schools  will  have  to  adopt  reasonable  standards  or  cease  to  exist. 
Then  also  every  medical  school  graduate  will  be  better  equipped 
not  only  to  present  more  acceptable  qualifications  for  the  license 
to  practice  medicine,  but  also — and  this  is  far  more  important — 
he  will  be  able  to  render  better  care  to  his  patients. 


EXAMINATIONS    I^OR    LICENSE    TO    PRACTISE    AND 
HOSPITAL  INTERNESHIP.i 

By  John  M.  Baldy,  M.D.,  Philadelphia,  President  of  the  Bureau  of  Medical  Education 
and  Licensure  of  the  State  of  Pennsylvania. 

Examinations  for  License  to  Practise. 

It  has  always  appeared  to  me  that  State  Boards  have  greatly 
misconceived  their  duties  as  regards  the  function  of  examina- 
tions for  license  to  practise  medicine.  Educationally,  we  have 
primary  and  secondary  school  work,  followed  by  college  work, 
as  preliminary;  this  is  followed  by  the  work  in  the  medical  school, 
and  finally  by  the  interneship  in  a  hospital,  prior  to  the  state 
examination.  Each  one  of  these  sub-divisions  begins  and  ends 
as  an  entity  and  each  one  is  competently  taught  and  competently 
passed  prior  to  entering  upon  the  succeeding  one.  In  passing 
from  the  high  school  to  the  college,  it  is  assumed  on  the  presenta- 
tion of  properly  certified  credentials  that  the  detail  of  the  high 
school  work  has  been  competently  performed,  the  teachers  have 
been  of  proper  competency  and  the  result  has  been  passed  on 
competently;  the  same  may  be  said  of  the  college  work  which 
follows,  on  entrance  to  the  medical  school ;  and  the  same  ought  to 
be  said  of  the  work  done  in  the  medical  school,  on  entrance  to 
the  state  medical  examination.  No  State  Medical  Examining 
Board  thinks,  when  examining  an  applicant  for  the  practice  of 
medicine,  of  re-examining  him  in  the  A  B  C's  nor  in  reading, 
writing  or  arithmetic.  No  State  Examining  Board  thinks  it 
necessary  to  pass  upon  his  qualifications  in  history,  geography 
and  the  higher  branches.  Physics,  chemistry,  biology  and  lan- 
guages are  not  taken  into  consideration  in  state  medical  examina- 
tions. If  this  be  true  of  the  work  up  to  the  medical  school  work, 
and  can  be  done  safely,  then  why  should  it  not  be  applied 
equally  well  to  the  work  done  in  the  medical  school  itself? 

Some  years  ago,  when  there  was  no  supervision  whatever  over 
the  medical  schools,  when  there  was  no  standardization  of  medical 
schools  and  when  State  Boards  well  knew  that  the  majority  of 


38 

medical  schools  did  not  teach  medicine  properly,  the  situation 
was  an  entirely  different  one.  At  the  present  time  medical 
schools  are  standardized.  The  weaker  ones  are  rapidly  elimi- 
nated. Proper  departments  with  proper  equipment  are  well  in 
hand;  competent  teachers  with  competent  and  sufficient  num- 
bers of  assistants  are  engaged;  the  State  inspects  the  schools 
and  assumes  responsibility  as  to  their  curriculum  and  teaching 
force.  This  being  true  there  is  no  more  reason  that  the  details 
of  their  work  should  be  reviewed  by  the  State  Examining  Board 
for  Licensure  than  there  is  that  the  State  should  review  the  pre- 
liminary work  of  the  primary  or  the  secondary  schools  or  the 
college.  The  function  of  the  State  briefly  stated  is  to  determine 
whether  or  not  the  applicant  wishing  to  practise  medicine  is 
competent  to  begin  to  do  so.  In  determining  this  it  is  none  of 
the  function  of  the  State  to  test  whether  or  not  the  applicant 
knows  all  the  details  of  all  the  various  fundamental  sciences 
necessary  for  the  preparation  for  graduation.  An  applicant 
having  been  graduated  from  a  competent  and  standardized  med- 
ical school  may  fairly  be  presumed  to  know  the  facts  of  the  basic 
sciences.  The  point  the  State  should  demand  to  know  is  whether 
or  not  he  can  correlate  these  facts  sufficiently  to  make  him  a 
safe  practitioner:  not  a  finished  practitioner  but  sufficiently 
safe  to  be  allowed  to  begin  practice.  This  to  me  is  the  entire 
function  of  the  State  in  these  matters  and  beyond  this  there  is 
no  necessity  to  go. 

It  is  utterly  impossible  for  any  student  to  learn  in  the  short 
time  devoted  to  the  study  of  medicine  all  the  facts  of  all  the  funda- 
mental sciences.  It  is  equally  impossible  for  him  to  carry  in 
his  mind  all  of  the  facts  that  he  does  learn  in  order  that  they 
may  be  available  at  an  examination  at  some  indefinite  time  in 
the  future.  I  may  state  further  that  it  is  not  even  desirable 
that  he  should  remember  them  all.  Study  does  not  predicate 
the  remembrance  of  everything  one  has  studied.  The  value  of 
study  is  the  training  it  has  given  the  mind  and  the  learning  of 
general  principles  and  principal  facts  which  have  a  practical 
applicability  to  future  work.  Many  men  perfectly  competent 
to  begin  the  practice  of  medicine  have  been  rejected  and  unfairly 


39 

handicapped  by  a  non-recognition  of  these  plain  and  fundamental 
facts.  Consequently  I  am  a  strong  believer  that  the  State  in 
its  licensing  examinations  should  not  examine  in  the  fundamental 
sciences  directly  but  that  it  should  confine  its  tests  in  regard  to 
the  knowledge  of  these  sciences  to  practical  questions  of  prac- 
tice, which  questions  cannot  be  answered  unless  the  applicant 
understands  the  general  principles  and  main  facts  of  the  under- 
lying sciences. 

For  instance,  I  am  strongly  opposed  to  asking  pure  anatomical 
questions,  physiological  questions  and  questions  on  inorganic 
and  organic  chemistry.  The  examiner  who  cannot  formulate 
his  pathological  questions  so  as  to  demonstrate  the  knowledge  of 
physiology  of  the  one  answering  them,  is  an  incompetent  examiner 
and  has  mistaken  his  calling.  The  examiner  who  cannot  put 
his  surgical  questions  in  such  a  manner  as  to  demonstrate  the 
knowledge  of  anatomy  of  the  one  answering  the  questions,  is 
similarly  disqualified  as  an  examiner.  No  man  uses  organic 
or  inorganic  chemistry  in  the  practice  of  medicine.  The  chemistry 
which  is  in  daily  use  by  him  and  which  he  should  understand 
thoroughly  is  physiological  chemistry  and  the  examination 
questions  should  be  confined  to  this  subject.  It  is  perfectly  fair 
to  presume  that  the  man  who  can  answer  his  surgical  questions, 
his  pathological  questions,  his  biochemical  questions,  under- 
stands a  sufficiency  of  the  three  underlying  sciences  for  all  prac- 
tical and  theoretical  purposes.  If  the  State  is  to  go  into  the  de- 
tails of  all  these  subjects  then  there  is  no  reason  why  it  should  not 
reach  further  back  and  test  out  the  applicant  as  to  whether  or 
not  he  understands  all  of  the  intricacies  of  physics,  of  geography, 
of  reading,  writing  and  arithmetic,  and  even  of  the  A  B  C's. 
There  must  come  a  point  when  it  is  perfectly  safe  to  cease  testing 
a  man's  knowledge  of  elementary  subjects  and  from  the  State 
viewpoint  I  am  very  emphatic  in  my  belief  that  that  point  is 
reached  as  indicated  above. 

Hospital  Interneship. 

To  demand  a  year  or  more  of  time  of  a  young  man  just  leaving 
the  medical  school  after  having  undergone  all  the  sacrifices  neces- 


40 

sary  to  his  medical  education,  is  a  serious  matter,  especially 
when  we  consider  the  age  at  which  the  average  medical  student 
leaves  the  medical  school.  Consequently,  when  the  State  de- 
mands an  interneship  of  a  period  of  time  in  a  hospital  it  is  bound 
to  see  that  the  hospital  providing  this  interneship  is  capable  of 
returning  to  the  interne  a  competent  quid  pro  quo  for  his  time 
and  his  sacrifice.  This  means  the  standardization  of  hospitals 
just  as  medical  schools  have  been  standardized  and  are  still  in 
process  of  being  standardized. 

It  is  not  the  intention  to  discuss  in  detail  the  organization  of 
all  departments  of  a  hospital;  this  has  been  done  many  times 
by  others  well  qualified  so  to  do  and  a  fair  understanding  ob- 
tains as  to  these  matters.  Rather  is  it  the  intention  in  a  general 
way  to  call  attention  sharply  to  those  departments  which  really 
go  to  make  up  a  true  hospital  but  which,  in  the  course  of  a 
systematic  and  fairly  exhaustive  inspection  of  over  two  hundred 
hospitals,  including  State-owned  hospitals,  the  Pennsylvania 
medical  authorities  have  found  to  be  very  generally  ignored; 
or,  if  in  existence  at  all,  were  in  such  a  large  number  of  instances 
found  to  be  so  poorly  developed  as  to  be  worthless  for  the  pur- 
pose of  proper  and  efficient  scientific  work,  either  as  aid  to  proper 
and  accurate  diagnosis  or  as  useful  for  instruction  of  an  interne. 

The  question  then  primarily  arises,  what  is  a  hospital?  From 
the  viewpoint  of  the  interneship  it  is  utterly  impossible  to  con- 
sider many  institutions  at  the  present  time  calling  themselves 
hospitals,  under  this  designation.  In  constructing  a  true  hos- 
pital certain  scientific  departments  should  first  be  provided  for; 
the  balance  of  the  hospital  should  be  built  around  these  depart- 
ments. Principally  these  departments  are:  the  pathological 
and  clinical  laboratories,  the  X-ray  department,  the  anesthetic 
department,  the  morgue  and  the  autopsy  room,  and  a  competent 
system  of  record-keeping  throughout  the  whole  institution. 
These  things  are  as  necessary  as  is  a  kitchen,  a  laundry,  a  super- 
intendent's office,  a  boiler  house,  the  medical  and  surgical  wards 
or  any  other  essential  department  and  no  institution  should  be 
dignified  with  the  name  of  hospital  without  each  and  all  of  them 
being   competently    provided   for.     It   were   supererogation    to 


41 

state  that  medicine  cannot  be  competently  practised  or  taught 
to-day  without  the  aid  of  these  departments,  and  if  this  be  true 
then  it  follows  as  a  matter  of  course  that  the  interne  cannot  be 
competently  educated  in  an  institution  which  does  not  provide 
these  facilities,  nor  can  the  patient  submitted  to  its  care  receive 
the  full  benefits  possible  from  modern  medicine.  In  attempting 
to  do  so  an  institution  does  not  give  either  the  interne  or  the 
patient  a  fair  and  proper  service.  For  an  institution  to  have 
these  departments  within  its  walls  is  not  sufficient.  Their  es- 
tablishment and  equipment  carries  with  it  the  supposition  that 
they  must  be  administered  by  a  proper  personnel.  By  a  proper 
personnel  it  is  not  meant  that  figure-heads  be  appointed  for  this 
work  but  that  men  and  women  with  a  full  technical  knowledge 
of  the  work  of  the  various  departments,  aided  by  competent 
assistants,  be  in  control ;  that  these  heads  be  active  in  their  duties 
and  that  they  be  of  such  a  type  as  to  be  able  to  impart  a  knowl- 
edge of  the  work  as  well  as  perform  the  work  of  their  several 
departments.  It  further  does  not  mean  that  these  departments 
should  exist  in  the  hospital  and  not  be  used  by  the  medical  and 
surgical  staff.  It  is  perfectly  patent  that  in  many  hospitals  the 
staff,  in  many  instances,  is  composed  of  men  unfitted  for  the  work 
assigned  to  them;  unfitted  not  only  as  teachers  of  the  interne 
but  unfitted  to  give  that  service  to  the  patients  submitted  to  their 
care  which  should  be  given,  in  accordance  with  the  possibilities 
of  modern  medicine. 

The  efficient  handling  of  the  scientific  departments  means 
team  work  on  the  part  of  every  one  throughout  the  whole  institu- 
tion. Staff  men  who  neglect  the  opportunities  offered  by  the 
scientific  departments  should  be  promptly  retired  and  should 
be  no  longer  tolerated  in  the  hospital's  service.  Team  work  in- 
volves not  only  the  co-operation  of  the  staff  men  with  the  labora- 
tories but  involves  also  the  co-operation  of  the  superintendents 
and  boards  of  managers.  If  a  sufficiency  of  budget  is  not  pro- 
vided competent  work  cannot  be  done  in  the  scientific  depart- 
ments for  lack  of  means  in  the  doing.  Consequently  boards  of 
managers  should  include  in  their  budget  ample  funds  for  carrying 
on  the  work  of  these  departments. 


42 

Superintendents  should  so  arrange  the  details  of  their  superin- 
tendency  that  certain  routine  work  goes  daily  to  the  laboratory, 
whether  or  not  the  staff  men  make  the  request.  For  instance, 
all  tissue  removed  in  the  operating  room  should  be  sent  routinely 
to  the  laboratories  for  investigation ;  certain  ward  material  should 
be  taken  routinely  to  the  laboratories  for  examination;  the  milk 
and  water  used  in  the  institution  should  be  investigated  system- 
atically and  periodically;  it  should  be  a  matter  of  routine 
that  all  vaginal  secretions  of  children,  smears  from  throat  infec- 
tions, sputum  from  possible  tubercular  cases  and  various  other 
conditions  should  be  carefully  studied.  If  staff  doctors  do  not 
care  for  the  information  derived  from  these  sources,  the  patients 
are  nevertheless  hospital  patients  and  the  hospital  should  secure 
the  proper  data  for  their  own  uses  and  records.  The  staff  man 
who  does  his  duty  and  is  worthy  of  appointment  will  use  the 
laboratories  freely  in  many  ways.  Without  this  no  hospital 
is  doing  its  full  duty  to  its  patients  and  it  is  entirely  neglecting 
its  duty  to  its  internes.  The  hospital  function  involves  the 
proper  scientific  treatment  of  its  patients,  and  the  education  of 
the  interne  as  its  principal  functions;  this  to  be  supplemented  by 
the  investigation  of  new  remedies  and  by  research  work  in  the 
larger  institutions. 

X-ray  department:  No  institution  in  these  days  of  workmen's 
compensation  acts  can  do  justice  to  its  clientele,  if  he  be  a  work- 
man or  employer,  without  the  full  and  competent  use  of  the  X-ray 
apparatus.  It  is  not  sufficient  that  the  function  of  this  depart- 
ment be  confined  to  primary  diagnosis.  Diagnosis  is,  of  course, 
one  of  its  principal  functions,  but  there  follows  immediately 
thereafter  the  great  importance  of  record-keeping.  To  illustrate : 
for  the  hospital  to  assume  in  the  case  of  a  fracture  or  dislocation 
that  its  duty  is  fulfilled  when  the  picture  of  the  injury  is  recorded, 
is  erroneous.  The  condition  of  this  injury  at  the  time  of  dis- 
charge and  supposed  cure  is  equally  as  important  and  should  in 
every  instance  be  recorded,  and  the  records,  in  the  shape  of  the 
radiograph,  should  be  properly  filled  and  preserved  for  a  period 
of  years. 

The  education  of  the  interne  in  the  matter  of  correctly  reading 


43 

plates  and  interpreting  them  is  equally  a  function  of  this  labora- 
tory. And  no  such  laboratory  is  complete  which  is  not  equipped 
for  and  actively  engaged  in  treatment  work. 

Records  of  all  departments  of  the  institution  are  a  requisite 
of  a  properly  standardized  hospital.  These  records  should 
cover  at  a  minimum,  alphabetical  admission  card,  a  record  card 
according  to  diseases,  history  sheets,  temperature  charts,  order 
sheets,  bedside  records,  operating  and  anesthetic  records,  labora- 
tory request  and  finding  sheets  with  card  index  in  the  laboratory, 
request  and  finding  sheets  with  card  index  in  the  X-ray  depart- 
ment, and  follow-up  cards,  all  carrying  the  house  number.  The 
laboratory  and  X-ray  number  should  appear  on  their  respective 
request  sheets.  In  addition  to  this,  in  the  laboratory  there  should 
be  filed  seriatim,  with  the  laboratory  number  attached,  all  slides 
and  paraffin  blocks.  In  the  X-ray  department  all  plates,  having 
attached  the  X-ray  laboratory  number,  should  be  filed  seriatim. 
It  should  be  essential  in  every  hospital  that  these  records  be  not 
only  in  existence,  but  that  they  be  systematically  and  fully 
recorded  and  then  properly  filed.  Here  again,  without  compe- 
tency in  the  superintendency  the  situation  becomes  hopeless. 
Records  properly  kept  are  a  source  of  education  to  those  making 
them;  are  a  source  of  the  utmost  value  to  future  diagnosis  and 
medico-legal  matters;  are  a  source  of  demonstration  of  the  effi- 
ciency of  the  work  done  in  every  department,  and  of  those  in 
control  of  the  work ;  and  are  a  fund  of  information  for  the  boards 
of  managers  as  to  the  competency  of  superintendents,  internes 
and  of  members  of  the  medical  and  surgical  staff.  By  reference 
to  the  laboratory  records  filed  in  the  office  any  board  of  managers 
can  tell  promptly  which  members  of  the  medical  and  surgical 
staff  are  engaged  in  the  scientific  practice  of  medicine  and  which 
are  mere  "prescription  writers,"  and  consequently  which  should 
be  retained  on  their  staff. 

The  interne  cannot  receive  a  competent  service  in  an  institu- 
tion which  is  manned  by  a  staff  whose  members  walk  through 
their  wards,  spend  a  few  minutes  with  their  patients,  make  few 
or  no  scientific  investigations,  do  not  discuss  their  cases  and  merely 
prescribe  drugs.     Such  a  service  is  worse  than  useless  to  the  in- 


44 

terne  and  in  nine  cases  out  of  ten  it  is  equally  useless  to  the  patient. 
The  interne  is  entitled  to  a  fair  measure  of  instruction  and  the 
authorities  should  demand  that  its  staff  members  explain  their 
cases  to  the  interne  in  the  course  of  the  rounds  and  that  the  ser- 
vice be  made  a  real  educational  one. 

It  is  rare  that  the  interne  will  receive  any  competent  service  in 
the  hospital  which  opens  its  doors  to  all  the  doctors  in  the  com- 
munity in  which  it  exists.  A  standard  hospital  should  have  a 
staff  carefully  picked  for  its  competency  in  all  departments 
and  the  work  in  the  wards  of  the  hospital  should  be  confined  to 
this  staff.  The  interne  should  receive  a  rotary  service  through- 
out all  departments,  the  service  being  so  arranged  that  he  will 
receive  a  maximum  of  time  in  each.  In  a  year's  service  in  a 
hospital  he  should  have  a  minimum  of  two  months  in  the  labora- 
tory alone  without  any  other  service  whatever  complicating; 
and  the  better  time  for  this  service  is  in  the  early  part  of  his  in- 
terneship.  During  this  service  he  should  be  at  the  command 
of  the  pathologist  alone  and  his  full  time  daily  should  be  spent 
in  this  department.  If  it  be  necessary  that  this  service,  because 
of  the  number  of  internes  employed  in  the  hospital,  be  cornbined 
with,  for  instance,  out-patient  work  or  siurgical  dressing  work, 
then  the  time  in  the  laboratory  should  be  increased  to  three 
months  or  more  in  order  that  the  interne  shall  have  received  the 
equivalent  of  a  full  two  months'  service,  as  a  minimum.  It 
goes  without  saying,  it  is  desirable  that  the  laboratory  service 
be  complicated  with  no  other  service  whatever. 

The  anesthetic  department  should  be  under  the  direction  of 
a  member  of  the  staff,  this  member  to  have  at  least  one  trained 
full-time  individual,  preferably  a  woman,  as  assistant.  During 
the  service  of  the  interne  in  this  department,  which  should  be  a 
distinct  and  definite  service,  there  should  always  be  a  watchful 
hand  kept  over  him  diu-ing  each  administration  of  anesthesia, 
throughout  his  full  term.  To  simply  instruct  a  new  interne, 
fresh  from  college,  for  a  week  in  the  giving  of  anesthesia  and  then 
to  allow  him  to  administer  it  for  the  next  two  months  without 
supervision  is  not  competent  for  the  safety  of  the  patient,  for 
the  comfort  of  the  surgeon,  or  for  the  education  of  the  interne, 


45 

and  should  not  be  tolerated.  One  or  more  full-time  individuals 
in  this  department  is  a  necessity  in  a  modern  hospital  and  should 
be  insisted  on.  The  work  of  the  anesthetizer  should  be  to  admin- 
ister anesthesia  in  certain  cases  and  to  educate  and  supervise 
the  interne  when  giving  the  anesthesia,  throughout  his  full  ser- 
vice. A  physician  living  out  of  the  hospital  and  practicing  med- 
icine is  not  competent  to  undertake  this  work;  few  hospitals 
can  afford  a  physician  on  full  time  for  such  work.  A  reasonable 
solution  is  the  woman  anesthetist,  preferably  a  former  trained 
nurse  especially  instructed  in  these  matters.  In  small  hospitals 
a  very  competent  and  economical  arrangement  may  obtain  by 
which  the  laboratory  technician  and  the  anesthetizer  may  be  com- 
bined in  the  same  individual;  the  responsibility  of  seeing  that 
the  records  throughout  the  hospital  are  properly  recorded  and 
filed  might  in  some  instances  be  properly  placed  in  the  same 
hands. 

The  lack  of  interest  in  autopsy  work  in  America  is  usually 
attributed  to  the  difficulty  in  obtaining  material  for  this  purpose, 
but  as  a  matter  of  fact  is  largely  due  to  indifference  on  the  part  of 
the  hospital  authorities.  An  effort  should  be  made  in  every  in- 
stance, especially  in  an  institution  with  educational  pretensions,  to 
obtain  this  material ;  the  pathologist  might  obtain  many  a  consent 
if  he  be  given  an  opportunity  to  do  so.  It  is  plainly  evident  that 
the  less  work  of  this  kind  performed  the  less  efficient  the  staff, 
the  less  reliable  the  records  and  the  less  vital  instruction  is  received 
by  the  interne.  This  indifference  is  one  of  the  greatest  defects 
of  the  American  hospital  and  a  supreme  effort  should  be  made 
to  rectify  it. 


LEGISLATION    CREATING   CIVIL   POSITIONS   FOR 
PHYSICIANS. 

By  John  B.  McAlister,  M.D.,  Harrisburg,  Penna.,  President  of  the  Medical  Society  of 
the  State  of  Pennsylvania. 

One  of  the  best  signs  of  the  medical  times  is  the  awakening 
of  the  medical  profession  to  the  importance  of  its  interests.  Med- 
ical journals  throughout  the  United  States  are  publishing  edi- 
torials and  articles  by  leading  physicians  in  which  the  question 
is  asked  "What  is  the  matter  with  our  profession?"  The  query 
differs  slightly  in  the  method  of  the  asking,  but  recurs  so  contin- 
ually that  clearly  enough  something  radically  wrong  exists  be- 
tween the  profession  we  represent  and  the  public. 

The  answer  to  the  question:  "What  is  the  matter  with  the 
medical  profession,"  is  of  vital  moment  for  more  than  one  hundred 
thousand  physicians  in  the  United  States.  They  are  all  agreed 
that  they  do  not  receive  adequate  pay  for  the  services  they  give 
the  public — be  that  service  rendered  in  the  family,  hospital  or 
dispensary;  whether  they  treat,  investigate  or  prevent,  not  only 
the  ordinary  ills  flesh  is  heir  to — but  contagious  or  epidemic 
diseases. 

In  both  hospital  and  private  practice  the  physician  is  the  chief 
ally  of  the  Board  of  Health  and  other  departments  of  the  state 
to  which  he  has  to  report  all  communicable,  epidemic  or  industrial 
diseases,  births  and  deaths,  under  a  penalty  of  a  fine  for  neglect; 
he  is  called  upon  to  assist  in  the  investigation  of  the  various 
causes,  treatments,  and  prevention  of  disease;  to  present  his 
practical  experience  thus  gained  in  recitations  before  his  medical 
society,  or  to  publish  them  in  journals  devoted  to  medical  lore. 
Finally,  he  is  expected  to  disseminate  his  accumulated  knowl- 
edge among  his  patients  for  their  use  and  benefit.  He  is  a  store- 
house of  scientific  and  useful  information  in  health  or  sickness, 
which  belongs  to  the  public  merely  for  the  asking.  He  thus 
literally  serves  the  state,  but,  unhke  all  other  servants  of  the  state, 
receives  nothing  for  his  services.     On  the  contrary,  every  effort 


47 

he  makes  to  prevent  disease  or  to  remove  disease  conditions 
helps  to  diminish  his  income. 

As  soon  as  a  physician  receives  his  coveted  degree  he  becomes 
an  interne  in  a  hospital  or  an  assistant  in  a  dispensary.  At  the 
same  time  he  becomes  an  altruist  and  a  philanthropist,  although 
these  latter  titles  are  not  commonly  recognized.  Upon  entering 
into  practice,  he  begins  his  own  destruction  and  annihilation, 
for  in  this  age  of  preventive  medicine  whereby  disease  will  ulti- 
mately be  eliminated,  the  physician  will  be  superfluous  and  the 
necessity  for  him  will  no  longer  exist. 

Until  that  happy  era  for  the  public  be  attained,  the  physician 
may  be  excused  if  he  be  permitted  to  look  a  little  to  his  interests, 
be  they  professional  or  legislative. 

It  is  doubtful  if  the  public  ever  would  have  had  its  attention 
called  to  the  threatened  plight  of  physicians,  or  if  the  physicians 
themselves  had  fully  realized  the  precipice  toward  which  they 
were  trending  had  it  not  been  for  the  fact  that  half  of  the  total 
number  of  physicians  in  the  United  States  had  not  organized 
themselves  into  the  great  and  influential  body  known  as  the  Amer- 
ican Medical  Association.  This  organization  has  been  carrying 
on  a  campaign  of  education  in  order  that  the  public  may  better 
understand  what  the  modern  physician  is  trying  to  do  for  human- 
ity's sake  and  how  he  is  hampered  personally  while  earnestly 
trying  to  prevent  and  cure  disease. 

It  is  estimated  that  probably  twenty  to  twenty-five  per  cent, 
of  a  physician's  work  is  done  for  charity,  either  directly  in  dis- 
pensary or  hospital  work,  or  in  private  practice  for  which  he  is 
not  paid.  Thus  it  is  that  to-day  the  living  to  be  made  from 
the  practice  of  medicine  is  a  precarious  one,  due  to  the  diminution 
of  disease  and  the  enormous  amount  of  medical  charity,  expected 
and  demanded  from  the  physician. 

If  more  civil  positions  with  adequate  remuneration  were  open 
to  physicians,  one  of  the  greatest  evils  against  our  profession 
would  be  removed — the  doing  of  work  gratuitously  for  which 
patients  are  able  to  pay.  Why  should  not  physicians  be  com- 
pensated as  are  other  employees  of  hospitals  and  dispensaries? 
Since  the  time  of  Hippocrates  the  physician  has  been  trained 


48 

t 

to  become  an  altruist,  to  treat  fees  with  indifference,  if  not  with 
contempt.  This  legendary  custom,  this  noble  but  impractical 
idea,  does  not  seem  to  square  well  with  the  20th  century  needs. 

Every  community  owes  to  the  doctor  more  protection  than  it 
bestows  upon  him.  Instead  of  giving  him  such  protection,  the 
laws  of  many  states  put  him  on  an  equal  footing  with  quacks 
and  clairvoyants.  If  the  present  indifference  to  the  educated 
physician's  rights  continues,  the  profession  of  medicine  will  cease 
to  attract  men  of  noble  ideals  and  good  preparatory  training, 
for  in  this  work-a-day  world  compensation  must  be  obtained  to 
meet  the  physical  wants  of  the  individual.  Conscientious  folk 
will  soon  be  forced  to  say  to  every  young  man  or  woman  who  has 
a  hankering  after  medical  study,  "Don't."  There  are  lots  of 
other  ways  of  making  a  comfortable  living  beside  medicine. 
While  it  is  the  noblest  of  professions  it  is  the  meanest  of  trades. 
It  must  be  admitted  that  the  public  obligations  to  physicians 
are  constantly  disregarded  in  the  unjust  discrimination  against 
them  by  our  lawmakers.  Power  to  remove  this  stigma  rests 
with  the  people.  In  ordinary  times  and  for  ordinary  matters, 
the  people  delegate  the  law-making  functions  of  the  national, 
state  or  municipal  legislative  bodies:  the  administrative  to  ad- 
ministrative bodies  similarly  divided;  and  the  judicial  functions 
to  the  judicial  machinery.  In  time  of  great  emergency,  how- 
ever, such  differentiation  is  swept  aside,  and  action  lies  solely 
with  the  people.  Is  it  too  much  to  hope  that  through  the  cam- 
paign of  education  put  forward  by  the  American  Medical  Asso- 
ciation, by  its  series  of  lectures  given  in  many  County  Medical 
Societies,  besides  lectures  to  Women's  Clubs,  Mothers'  and 
Teachers'  Organizations,  Young  Women's  Christian  Associa- 
tions, Church  and  Settlement  Clubs  (10,000  such  lectures  since 
1909)  will  bring  its  reward,  leaving  the  physician's  case  to  be 
acted  upon  by  the  people  whom  he  has  always  so  self  sacrificingly 
served? 

Medicine  is  more  and  more  becoming  a  function  of  the  State 
and  physicians  soon  must  look  to  the  State  for  their  support. 
Who  is  to  teach  the  people  the  great  truths  of  preventive  medi- 
cine except  they?     Are  they  asking  more  than  their  just  rights 


49 

that  the  State  who  depends  so  largely  upon  them  should  pay 
them  a  living  wage?  Public  health  is  a  science  and  one  to  be 
carried  on  by  scientifically  trained  minds.  To  handle  the  vital 
problems  of  public  health,  to  wage  the  battle  against  the  powers 
of  disease,  and  the  pain  with  which  they  torture  mankind,  physi- 
cians and  surgeons  must  take  their  places  in  the  forefront.  They 
are  the  captains  who  order  the  fights,  discover  the  vulnerable 
points,  map  out  the  campaigns  and  lead  the  forces  on  to  the  battle- 
field. Men  must  be  trained  for  this  important  work,  and  having 
been  trained,  have  a  moral  and  legal  right  to  be  placed  in  posi- 
tions where  they  must  serve  mankind  by  applying  this  training 
they  have  so  expensively  and  painstakingly  acquired. 

The  important  point  of  contact  between  the  Law,  Medicine, 
and  the  State  is  the  Public  Health  Service  as  supervised  by 
State  and  Local  Boards  of  Health.  In  order  to  meet  the  new 
conditions  this  entire  system  needs  change,  enlarging  and  strength- 
ening. It  is  a  significant  fact  that  although  local  and  State 
Boards  of  Health  are  so  dependent  upon  and  so  closely  allied  with 
the  medical  practitioners  of  the  City  or  State,  yet  but  6  per  cent, 
of  those  employed  by  such  Boards  of  Health  are  regular  physi- 
cians. Can  war  be  waged  successfully  upon  disease  until  the 
whole  medical  profession  is  under  control  of  the  State?  Until 
such  a  consummation  be  reached,  it  is  vain  to  hope  that  every 
individual  in  the  community  can  be  subjected  to  proper  medical 
inspection  or  receive  adequate  medical  treatment. 

Heroic  measures  are  necessary  if  the  health  of  the  State  be- 
comes the  important  part  of  the  State  administration  it  deserves. 
One  of  the  first  and  most  important  requisites  is  the  immediate 
organization  of  every  medical  institution  and  clinic  in  every  city 
under  one  head.  This  head  should  preferably  be  a  State  Health 
Commissioner  and  a  strong  executive.  A  Board,  or  Committee, 
or  Bureau,  or  whatever  any  aggregate  or  individual  may  be 
called,  is  never  as  successful  in  executive  work  as  one  person  to 
whom  much  power  is  granted,  of  whom  much  is  expected.  He 
may  be  called  anything  the  State  desires,  but  his  province  should 
be  to  appoint  his  subordinates,  who,  as  far  as  possible,  should  be 
efiicient  physicians  trained  in  public  health,  and  then  pay  them 


50 

salaries  adequate  to  permit  them  to  give  their  entire  time  to  the 
service  demanded  of  them. 

The  only  obstacle  in  securing  such  an  executive  is  the  part 
politics  plays  in  the  appointment  of  civil  positions.  If  anyone 
can  devise  a  plan  whereby  politics  be  removed  from  civil  posi- 
tions, especially  those  with  fair  salaries  attached — what  seems 
an  impossibility  will  become  an  easy  probability.  It  remains 
for  the  people  to  waken  up  to  a  realization  that  their  executive 
should  work  for  the  State  and  not  for  any  political  party. 

Several  states  have  minimized  political  complications  by  giving 
the  organized  medical  societies  an  important  place  in  the  admin- 
istration of  their  Health  Department.  It  must  be  admitted  that 
satisfactory  health  work  has  been  accomplished  in  some  of  these 
states  and  under  such  a  system,  but  it  must  also  be  recognized 
that  equally  good  work  has  resulted  from  other  forms  of  organ- 
ization in  other  states. 

At  present  the  head  of  the  State  Health  Department  is  ap- 
pointed by  the  Governor  in  less  than  a  third  of  the  States.  This 
seems  a  good  plan  in  that  responsibility  is  thus  centered  upon 
one  man ;  and  on  the  other  hand,  every  time  there  is  a  new  gover- 
nor the  executive  of  this  important  Health  Department  may  be 
removed — an  unfortunate  possibility,  for  surely  he  gains  an  added 
usefulness  to  the  people  every  year  he  holds  office  and  should 
not  be  removed  except  for  personal  derelictions  or  manifest  un- 
fitness for  the  office. 

A  Board  of  Health  exists  in  every  State  in  the  Union  except 
one.  The  State  Health  Officer  is  elected  by  this  Board,  a  custom 
which  prevails  in  thirty  states.  Such  selection  of  the  State  Health 
Officer  does  not  entirely  remove  the  office  from  politics,  but  it 
does  lessen  its  chances  of  becoming  part  of  the  patronage  sys- 
tem. 

Local  health  officers  and  their  subordinates  must  be  good  men, 
trained  by  the  State  in  all  that  pertains  to  their  positions.  How 
they  are  selected  is  of  great  importance  and  their  selection  should 
be  decided  by  each  State  by  carefully  drawn-up  legislation.  Such 
legislation  should  be  intelligent,  uniform  and  accurate. 

Legislation  should  take  notice  of  the  fact  that  even  the  best 


51 

men  cannot  work  without  just  and  fair  compensation.  This 
compensation  should  be  fixed  by  the  State. 

Appointments  of  health  officers,  whether  federal,  state  or  local, 
should  depend  entirely  upon  professional  qualifications,  and 
tenure  of  office  be  based  absolutely  upon  efficiency.  Such  ser- 
vants should  not  be  permitted  to  engage  in  any  duties  other 
than  their  regular  official  ones.  Stirely  the  services  of  the  guardians 
of  the  public  health  are  as  important  as  those  of  county  sheriff 
or  attorney. 

When  such  provisions  are  recognized  and  enforced  by  law, 
organizations  which  care  for  the  public  health  will  become  more 
highly  standardized  and  win  a  higher  respect  from  the  people  at 
large.  Their  next  step  in  attractiveness  will  be  that  regular 
physicians  will  prepare  for  and  desire  to  be  appointed  to  the 
many  positions  which  now  are  dubbed  civil  ones,  but  will  gradually 
evolute  until  they  are  held  absolutely  by  professional  physicians, 
carefully  educated  and  especially  trained. 

Stop  talking — stop  criticising  the  health  organizations  of 
your  State  and  pull  together  until  you  have  forced  a  more  satis- 
factory state  of  affairs.  You  have  more  power  than  you  have 
any  knowledge  of.  I  am  appealing  to  your  self-interest,  you  see. 
You  have  the  power  to  demand  and  enforce  wise  legislation. 
You  can  raise  efficiency  to  a  high  level  and  standardize  it.  You 
can  keep  health  legislation  and  health  administration  out  of 
politics.  To  accomplish  these  Utopian  conditions,  you  must 
co-operate  with,  and  stand  by,  the  health  officers  the  State  now 
supports,  if  you  desire  to  lend  a  hand  in  advancing  the  health 
work  and  health  organization  of  the  State  you  call  your  own. 

The  organization  of  the  public  health  of  a  State  must  not  neglect 
providing  for  the  training  of  workers  it  requires  for  its  own  ser- 
vice. Outside  institutions  may  train  men  for  the  higher  posi- 
tions but  the  masses  of  workers  in  any  State  system  must  be 
trained  in  the  State  where  they  later  expect  to  be  employed.  As 
long  as  the  State  neglects  to  provide  for  this  training  it  will  be 
weak  in  one  of  the  most  vital  links  in  the  chain  it  is  endeavoring 
to  forge. 

This  training  can  be  obtained  nowhere  so  well  as  in  the  uni- 


52 

versities  which  are  maintained  by  the  State.  In  Germany, 
all  universities  are  under  State  control,  and  nearly  all  medi- 
cal instruction  gained  in  such  universities;  therefore  the 
State  has  recognized  its  duty  in  educating  the  physicians  who 
later  save  the  lives  of  its  people.  In  Austria,  Hungary  and 
Switzerland  all  the  universities  are  State  ones,  and  in  Holland  with 
but  one  exception.  In  Great  Britain  originally  all  its  universi- 
ties were  private  ones,  but  they  have  gradually  passed  to  those 
of  State  control  except  Oxford,  Cambridge,  and  a  few  others. 

When  our  physicians  are  trained  in  universities  supported  by 
the  State,  it  will  seem  but  one  step  forward  for  them  to  be  placed 
in  hospitals  and  institutions  for  caring  for  the  sick  and  dependent 
classes.  '  All  such  institutions,  including  insane  asylums,  should 
be  in  conjunction  with  State  universities  whose  graduates,  upon 
completing  their  courses,  should  find  their  way  into  State  insti- 
tutions where  they  will  receive  a  fair  compensation  for  their 
services,  and  thus  more  closely  cement  the  bonds  between  public 
health  and  the  medical  profession. 

How  may  such  reform  be  obtained?  In  a  democracy,  where 
people  govern  themselves,  there  is  one  way  and  one  only.  By 
legislation  which  should  voice  the  desires  and  the  needs  of  those 
who  are  most  intimately  concerned.  In  all  medical  legislation 
the  interest  of  the  physician  has  been  singularly,  and  almost 
hopelessly,  disregarded.  It  is  due  to  this  fact  that  the  question 
is  being  asked,  "What  is  the  matter  with  the  medical  profes- 
sion?" It  remains  for  the  doctors  themselves  to  cure  such  condi- 
tions. How  may  they  do  it?  By  associating  themselves  with 
the  medical  societies  of  their  State  and  by  organization,  co-opera- 
tion and  determined  efforts,  force  their, rights  before  the  public, 
which,  after  all,  is  fair-minded  and  remembering  the  great  debt 
of  gratitude  it  owes  to  the  physician,  will  exercise  all  the  power 
it  has  to  insist  that  doctors  receive  fair  treatment  at  the  hands 
of  the  legislators.  This  the  public  will  do  when  once  it  under- 
stands the  true  conditions  under  which  we  suffer. 

To  facilitate  the  bringing  about  of  such  a  desired  improvement, 
bills  relating  to  public  health  must  be  carefully  drawn  by  men 
with  practical  knowledge  of  the  legislative  needs  as  far  as  public 


53 

health  is  concerned.  This  has  not  been  so  in  the  past.  Out  of  one 
thousand  bills  upon  health  matters,  introduced  into  42  legisla- 
tures last  year,  most  of  them  came  under  the  head  of  fads.  We 
need  fewer  laws  carefully  framed,  and  so  critically  considered 
before  adoption,  as  to  avoid  the  trouble  and  confusion  that  care- 
less legislation  entails. 

While  many  of  these  laws  introduced  were  unimportant,  yet 
several  were  passed  and  enforced  which  have  done  much  to  ad- 
vance the  medical  health  of  the  nation.  It  is  not  too  optimistic 
to  hope  that  when  physicians  have  roused  themselves  to  an  ap- 
preciation of  their  power,  they  will  enforce  legislation,  which  will 
raise  their  economic  status,  so  that  they  may  reap  a  fair  reward 
for  their  arduous  and  oft-unrequited  labors  in  behalf  of  humanity. 
With  civil  positions  offering  legitimate  compensation  open  to 
physicians,  with  an  assurance  of  his  continuance  in  same  as 
long  as  he  makes  good — ^with  reasonable  chance  of  promotion — 
with  services  in  hospitals,  dispensaries  and  institutions  open  to 
the  graduate  of  our  medical  colleges,  fair  salaries  being  attached 
thereto;  with  the  years  of  his  unrepaid  labor  lessened  by  the  two 
or  three  he  was  expected  to  serve  as  an  unpaid  interne  before  he 
dare  hang  out  his  shingle — with  the  cost  of  his  medical  education 
reduced  from  $10,000  to  $1,000 — his  charity  work  paid  for  by  the 
State  which  directly  benefits  by  it — then  I  dare  to  hope  that  my 
profession  and  yours  may  retain  the  high  ideals  for  which  it  has 
always  stood,  and  for  which  it  will  ever  fight  instead  of  being  al- 
lowed to  sink  to  the  depths  of  sordid  commercialism. 


SOCIAL    INSURANCE    AGAINST    ACCIDENTS    (WORK- 
MEN'S COMPENSATION  LAWS). 

By  Frbdbrick  L.  Van  Sickle,  M.D.,  Olyphant,  Pa. 
"THE   FAITHFUL  LABORER   IS   WORTHY  OF  HIS  HIRE." 

Workmen's  Compensation. 

In  studying  the  evolution  of  incomes  and  of  means  whereby 
the  people  of  the  world  are  supported,  either  by  hand  or  brain, 
it  is  well  to  make  some  investigation  as  to  the  changes  which  have 
taken  place  in  the  past  twenty  years,  whereby  a  gradual  evolu- 
tion of  wages,  salaries  and  earnings  has  been  granted  to  the 
working  and  middle  classes  of  the  people  of  this  and  foreign 
countries,  which  is  evidenced  by  the  present  state  of  wages  with 
their  increase,  as  compared  to  those  paid  in  times  gone  by. 

It  is  very  difficult  to  get  a  table  of  comparisons  from  which 
each  section  of  a  country  as  large  as  the  United  States  can  be 
workt  out,  because  there  enters  into  such  estimates  many  fac- 
tors that  deal  with  local  conditions,  with  the  sale  of  commodi- 
ties and  with  the  general  standing  of  prices  of  all  things  entering 
into  the  cost  of  living;  but  it  is  well  known  from  statistics  gathered 
by  industrial  organizations,  that  in  cases  where  the  wages  of  a 


55 

daily  laborer  twenty  years  ago  ranged  from  $i.io  to  $1.25  per 
day  of  ten  hours,  the  present  wage  would  not  be  less  than  $1.95 
to  $2 .  25  per  day  of  eight  hours  for  similar  labor. 

Again,  comparing  the  wages  of  a  higher  grade,  for  instance — 
mechanics,  carpenters,  bricklayers  and  masons,  the  wages  of 
twenty  years  ago  would  run  from  $2 .  00  to  $2.25  per  day  of  ten 
hours,  whereas  in  19 16  the  earnings  of  most  of  the  states  would 
give  us  an  average  of  from  $3.00  to  $4.00  per  day  of  eight  to 
nine  hours,  for  the  same  grade  of  labor. 

Again,  taking  a  higher  class,  a  more  skilled  workman  or  men  in 
salaried  offices,  we  find  that  whereas  $50  to  $75  per  month  was  a 
fair  income  some  years  ago,  the  same  work  to-day  brings  from 
$100  to  $150  per  month. 

It  is  unnecessary  for  us  to  go  into  detail  regarding  the  reasons 
for  giving  these  advances,  as  they  are  too  well  known  for  dis- 
cussion. 

A  most  vital  reason,  however,  is  the  greater  considera- 
tion for  labor  by  capital,  as  a  necessary  part  of  its  equipment 
and  a  greater  coming  together  of  the  two  units,  thru  which  greater 
concessions  are  granted  in  time  of  working  hours,  in  vacation 
periods,  and  furnishing  means  which  afford  not  only  the  necessi- 
ties of  life,  but  aiding  in  supplying  the  comforts  and  pleasures 
which  up  until  the  present  decade  were  almost  deprived  to  a  large 
class  of  the  working  people  of  the  nation. 

In  considering  this  featiure  of  the  workmen  of  the  world,  we 
must  realize  what  has  entered  into  this  problem  from  the  various 
influences  which  have  cemented  the  closer  relationship  with 
labor  and  capital  and  that  another  means  of  rendering  aid  has 
been  brought  about  by  the  passage  of  various  laws  in  foreign 
countries  and  in  the  United  States,  whereby  in  time  of  injury- 
compensation  was  granted,  making  the  path  of  the  injured  more 
easy,  the  trials  and  hardships  of  the  family  more  tenable,  the  pain 
and  suffering — while  not  abolisht — ^rendered  more  bearable, 
with  the  thought  that  the  wage  earner  was  not  without  means 
of  sustenance  for  himself  and  family  in  the  dark  hour  of  trouble. 
For  the  most  part  these  liberal  laws  have  been  termed  "Work- 


56 

men's  Compensation  Acts,"  in  which  we  find  capital  with  a  de- 
sire to  promote  the  best  interests  of  that  unit  of  their  organiza- 
tion, namely — ^labor — not  only  paying  for  part  of  the  time  lost, 
but  furnishing  the  workmen  with  a  more  prompt,  rapid  and  sys- 
tematic course  of  treatment  and  relief  for  their  injuries. 

It  cannot  be  said  that  these  laws  were  past  with  any  idea  of 
placating  or  relieving  the  responsibihty  which  labor  placed  upon 
capital,  but  with  an  eye  single  to  promoting  the  best  interests 
of  the  working  world,  bringing  to  the  people  to  whom  it  was  most 
needed  a  beneficial  system  of  conducting  the  treatment  of  in- 
jiured  persons,  whereby  correct  data  might  be  obtained  as  to  the 
kind  of  injury,  the  method  of  treatment,  the  length  of  time 
necessary  to  restore  health,  the  value  of  trained  observation 
and  the  greater  availability  of  statistics  which  bring  to  the  en- 
tire world  that  which  in  previous  times  and  previous  methods 
was  of  unknown  quantity  and  of  little  value. 

The  tedious  and  cumbersome  acts  which  were  first  produced 
have  been  repeatedly  modified,  amended  and  altered,  so  that 
at  the  present  time  the  thirty-two  states  of  the  Union  having 
these  meastues,  represent  a  vast  step  forward  toward  perfecting 
a  system  of  workmen's  compensation  that  is  doing  an  immense 
amount  of  good. 

In  the  United  States  we  find  on  investigation  of  the  various 
tables  of  comparisons  in  most  of  the  states  having  compensation 
laws  that  among  the  working  people  the  annual  income  of  the 
employe  is  based  at  $1000  a  year,  and  from  that  figure  has  been 
workt  out  a  scheme  of  indemnity  liberal  to  what  was  in  vogue 
in  times  past. 

The  principle  of  workmen's  compensation  universally  adopted 
is  a  reversal  of  the  previous  employers'  liability  acts,  under 
which  the  employer  paid  damages  only  when  the  accident  was  due 
to  his  fault  or  the  fault  of  his  fellow-servant,  etc.;  whereas  these 
new  laws  place  the  financial  burden  of  all  industrial  accidents 
which  happen  to  its  workmen  upon  the  industry  and  the  com- 
modity produced  and  the  workers  who  happen  to  be  the 
victims  of  particular  accidents  are  not  subjected  to  the  financial 
drain  which  existed  under  the  former  condition. 


57 

In  computing  the  cost  and  fixing  the  price  of  the  finisht  product, 
capital  computes  its  industrial  losses  due  to  accidents  as  those 
of  other  fixt  charges,  namely — wages,  machinery,  etc.,  etc. 

We  are  appalled  at  the  awful  sacrifice  of  life  in  the  European 
war,  but  the  condition  of  the  industries  of  the  United  States 
furnishes  us  with  an  unwelcome  parallel  of  fatalities  in  the  indus- 
trial world,  as  given  by  the  industrial  accident  commissions  of 
the  United  States. 

In  California  dining  the  year  19 14  there  were  62,211  industrial 
accidents,  of  which  678  were  fatal,  1292  permanent  injuries 
and  60,241  temporary  injuries. 

In  Michigan  during  the  year  19 15  the  number  of  fatal  accidents 
was  332 ;  number  of  accidents  causing  loss  of  member,  972 ;  num- 
ber of  accidents  causing  disability  for  more  than  two  weeks, 
12,188;  number  of  accidents  causing  disability  for  less  than  two 
weeks,  26,289. 

In  Pennsylvania  from  January  i,  1916,  the  date  upon  which 
the  new  Workmen's  Compensation  Act  of  Pennsylvania  went 
into  effect,  up  to  May  10,  19 16,  there  have  been  more  than  800 
working  men  and  women  who  have  lost  their  lives  in  the  course 
of  their  employment;  21  mine  workers  were  killed  in  three  coun- 
ties of  the  anthracite  coal  fields  and  over  80,000  injmies  were  in- 
flicted upon  the  workers  of  the  state.  Similar  reports  from  all 
other  states  might  be  quoted  were  space  permitted. 

The  time  has  arrived  when  the  humanitarian  feeling  has  per- 
vaded the  public  mind  and  public  opinion  has  so  imprest  capital 
that  there  is  an  increasing  consideration  for  the  man  who  works 
with  his  hands. 

The  Michigan  Industrial  Accident  Board  in  carrying  out  the 
theory  of  Workmen's  Compensation  Law,  says: 

The  law  should  be  supported  to  the  end: — 

That  the  injured  workmen  may  receive  justice. 

That  employers  may  have  fixt  liabilities  and  escape  the  embarrassment 
and  expense  of  damage  suits. 

That  the  courts  may  be  relieved  of  the  time  of  trying  damage  suits. 

That  the  public  treasury  may  be  relieved  of  the  expense  of  these  damage 
suits. 


58 

That  the  public  may  be  relieved  of  the  expense  of  caring  for  the  victims  of 
industrial  accidents. 

That  more  harmonious  relations  be  promoted  between  employers  and 
employes. 

It  further  says  that  the  cardinal  principles  of  a  compensation 
law  should  be: 

Reasonable  compensation  at  minimum  cost  for  all  accidents  except  the 
result  of  wilful  fault. 
Certainty  of  amount. 
Certainty  of  payment. 
Payment  without  litigation. 
Prevention  of  accidents. 

We  may  draw  the  inference  from  the  attitude  taken  by  com- 
pensation commissions  that  there  is  a  most  liberal  desire  on  the 
part  of  these  boards  to  pay  what  the  tariff  of  the  industry  can 
afford,  relieving  thereby  the  public  from  previous  burdens  borne 
in  the  name  of  the  so-called  charity;  hospital  abuse  in  its  various 
forms  to  be  relieved  and  overcome;  the  ambulance  chasing  at- 
torney caused  to  seek  legitimate  fields;  the  typical  medico-legal 
expert  ( ?)  in  liability  suits  relegated  to  the  dim  past,  and  the  many 
evils  attendant  upon  a  system  of  payment  for  industrial  injuries 
which  never  reacht  the  ideal  of  modem  times. 

We  can  well  understand,  therefore,  why  workmen's  compensa- 
tion or  industrial  insurance  has  attained  such  wonderful  promi- 
nence in  legislativ  halls,  lawyers'  gatherings,  among  sociological 
workers  and  professions  of  all  kinds,  whose  aim  it  is  to  bring  about 
the  modern  scientific  plans  for  relief  and  the  growth  that  appears 
the  more  phenomenal  when  we  reflect  upon  the  miserable  failure 
of  liability  statutes  and  the  earlier  compensation  acts  when 
subjected  to  the  microscopic  eye  of  the  supreme  tribunals. 

The  operation  of  the  compensation  laws  in  the  states  has  natur- 
ally encroacht  upon  the  business  of  the  legal  profession;  has  altered 
the  relationship  of  court  procedure;  has  in  its  effect  to  systematize 
its  application;  made  changes  in  relation  to  the  patient  and  the 
medical  profession,  but  its  principles  are  right  and  all  of  us  who 
are  influenced  by  its  various  provisions  must  take  the  bitter 
with  the  sweet;  must  realize  the  upward  tendency,  no  matter 
what  the  cost  may  be  to  personal  interests;  and  we  and  all  pro- 


59 

fessions  and  all  sociologic  workers  must  lend  our  support  to  an 
object  which  is  to  preserv  the  safety,  the  happiness  and  the 
peace  of  mind  of  the  people  of  the  states  and  the  Union,  and  we 
should  urge  hearty  support  in  all  states  having  compensation 
acts  and  prevail  upon  legislatures  in  states  not  having  these  mod- 
ern measures  to  cause  them  to  be  enacted  as  soon  as  possible. 

I  can  no  better  illustrate  the  thought  in  relation  to  the  working 
classes  of  the  United  States  in  my  feeling  toward  compensation 
laws  than  to  quote  the  language  of  Chief  Justice  Winslow,  of  the 
Supreme  Court  of  Wisconsin,  handed  down  in  case  of  Driscall 
vs.  Allis-Chalmers  Co.,  who  has  the  following  to  say: 

It  gives  me  no  pleasure  to  state  these  long  establisht  principles  of  the 
law  of  negligence.  I  have  no  fondness  for  them.  If  I  were  to  consult  my 
feelings  alone  I  would  far  prefer  to  let  the  case  pass  in  silence.  No  part 
of  my  labor  on  this  bench  has  brought  such  heart-weariness  to  me  as  that 
ever-increasing  part  devoted  to  the  consideration  of  personal  injury  actions 
brought  by  employes  against  their  employers.  The  appeal  to  the  emotions 
is  so  strong  in  these  cases,  the  results  to  life  and  limb  and  human  happiness 
so  distressing,  that  the  attempt  to  honestly  administer  cold,  hard  rules  of 
law  which  either  deny  relief  entirely  or  necessitate  a  new  trial,  make  draughts 
upon  the  heart  and  nerves  which  no  man  can  appreciate  who  has  not  been 
obliged  to  meet  the  situation  himself.  If  it  be  said  that  some  of  these  rules 
are  archaic  and  unfitted  to  modem  industrial  conditions,  I  do  not  disagree; 
in  fact  that  has  been  my  own  opinion  for  long.  Upon  reflection  it  seems  that 
this  could  not  be  otherwise.  Principles  which  were  first  laid  down  in  the 
days  of  the  small  shop,  few  employes  and  simple  machinery  could  hardly  be 
expected  to  apply  with  justice  to  the  industrial  conditions  which  now  sur- 
round us.  In  those  earlier  days  the  laborer  ordinarily  knew  his  fellow  work- 
men, workt  with  simple  machinery  and  ran  comparatively  small  risk  of 
injury.  The  genius  of  our  present  remarkable  industrial  development  re- 
quires that  he  carry  on  his  patient  toil  in  company  with  veritable  armies  of 
fellow  men,  many  of  whom  he  can  neither  see  nor  know;  it  surrounds  him 
with  mighty  and  complicated  machinery  driven  by  forces  beyond  his  control, 
whose  relentless  strength  rivals  that  of  the  thunderbolt  itself;  and  it  re- 
quires him  to  labor  day  by  day  with  faculties  at  highest  tension  in  places 
where  death  lurks  in  ambush  at  his  elbow,  waiting  only  a  moment's  inad- 
vertence before  it  strikes.  The  faithful  laborer  is  worthy  of  his  hire  in  these 
latter  days  as  never  before,  but  is  he  not  entitled  to  more,  and  are  not  those 
dependent  upon  his  labors  entitled  to  more?  When  he  has  yielded  up  life, 
or  limb,  or  self  in  the  service  of  that  marvelous  industrialism  which  is  our 
boast,  shall  not  the  great  public  for  whom  he  wrought  be  charged  with  a 
duty  of  securing  from  want  the  laborer  himself,  if  he  survive,  as  well  as  his 


6o 

helpless  and  dependent  ones?  Shall  these  latter  alone  pay  the  fearful  price 
of  the  luxuries  and  comforts  which  modern  machinery  brings  within  the 
reach  of  all?  These  are  burning  and  difficult  questions  with  which  the  courts 
can  not  deal,  because  their  duty  is  to  administer  the  law  as  it  is,  not  to  change 
it;  but  they  are  well  within  the  province  of  the  legislativ  arm  of  the  govern- 
ment. Happily  the  Legislature  has  seen  the  need  and  now  has  these  ques- 
tions under  serious  consideration.  If  it  shall  solve  them  justly  and  equitably 
within  constitutional  limits,  or  even  make  a  substantial  advance  in  the 
direction  of  such  a  solution,  it  will  be  entitled  to  the  gratitude  of  all  citizens. 
Confidently,  I  can  say  that  none  will  welcome  such  a  solution  more  heartily 
than  the  judges  of  the  courts. 

Physicians'  Compensation. 

The  history  of  medicine  from  the  days  of  Aesculapius  and 
Hippocrates,  placing  medicine  on  so  difficult  a  plane  with  the 
question  of  recompense,  or  in  other  words,  the  question  of  work- 
man's hire,  has  shown  it  to  be  the  most  difficult,  irregular,  irre- 
sponsible business  asset  that  any  class  of  men  could  have  ac- 
cepted in  any  walk  of  life. 

Recompense  for  services  rendered  has  been  almost  the  last 
thought  for  many  generations,  of  men,  and  later  women,  engaged 
in  the  healing  art.  This  early  training  and  moulding  of  thought 
has  had  much  to  do  with  the  stagnant  and  apathetic  condition 
pervading  the  great  mass  of  the  profession,  so  much  so  that 
business  matters  failed  to  receive  the  attention  or  discussion 
that  has  been  so  markt  in  almost  every  walk  of  life  and  business 
profession,  other  than  ours. 

It  makes  it  very  difficult,  therefore,  to  enter  into  a  discussion 
of  the  business  side  of  the  profession,  even  as  it  relates  to  the  mod- 
ern assets  of  our  business,  to  the  newer  fases  that  have  been 
thrust  upon  us  by  the  kaleidoscopic  change  in  the  business  world. 

We  have  ever  been  loathe  to  discuss  the  question  of  wages, 
or  income,  or  salary,  or  fees,  with  that  serious,  solid,  business 
sense  that  should  have  received  a  much  earlier  consideration  at 
our  hands,  and  as  a  result  the  condition  of  the  medical  profession 
this  day  is  almost  at  the  same  ebb  as  that  of  our  forefathers. 
Many  of  the  things  that  have  occurred  to  us  in  a  business  way 
have  been  thru  oiu:  own  lack  of  interest  in  the  financial  side  of 
the  work  and  much  can  be  laid  at  our  own  doors  from  our  own 
apathy. 


6i 

When  we  consider  how  Httle  attention  has  been  paid  to  the 
various  legislativ  acts  during  their  discussion  in  the  pubHc  press, 
in  public  assembHes  and  in  legislativ  halls,  we  cannot  but  agree 
with  the  statement  made  February  24,  1916,  by  Harry  A.  Mackey, 
Chairman  of  the  Workmen's  Compensation  Board  of  the  State 
of  Pennsylvania,  when  he  says: 

If  the  medical  men  feel  that  the  Pemisylvania  Act  is  somewhat  restrictiv 
upon  their  profession,  it  might  be  well  for  them  to  remember  that  probably 
they  did  not  take  the  same  care  of  their  interests  that  the  employer  and 
employe  did  at  a  time  when  their  advice  would  have  been  very  welcome  and 
most  instructiv. 

He  also  gives  us  this  advice: 

But  we  are  in  a  period  of  experimentation  and  if  the  next  twelve  months' 
experience  with  this  law  proves  that  your  (medical)  profession  has  any  real 
grievance,  the  Board  will  feel  itself  especially  commissioned  to  present  those 
results  to  the  next  Legislature  for  the  purpose  of  correction. 

The  same  thought  should  be  capitalized  by  medical  men  in 
every  state,  should  be  a  stepping  stone  upon  which  to  advance 
their  interests,  financially  and  economically,  when  new  acts 
are  to  be  framed  under  workmen's  compensation  laws. 

As  a  comparison  of  increase  it  was  stated  by  the  late  Dr.  Bris- 
tow  in  an  address  before  the  New  York  Academy  of  Medicine, 
about  19 13,  that  of  the  annual  income  of  male  adults  in  the  United 
States  90  per  cent,  is  less  than  $600,  and  fully  50  per  cent,  is 
less  than  $500,  with  20  per  cent,  as  low  as  $200  per  annum. 

As  a  comparison  to  this,  it  was  stated  somewhere  about  the 
beginning  of  19 10  that  the  average  earning  of  the  medical  pro- 
fession of  the  United  States  was  $750  per  annum.  Taking  this 
as  a  basis  of  comparison,  we  find  that  the  working  classes  have 
an  income  which  was  not  so  much  less,  proportionate,  than  that 
of  the  medical  profession. 

Since  19 13  there  has  been  a  gradual  increase  of  wages  and 
income  in  the  United  States  among  the  working  classes,  whereby 
from  10  per  cent,  to  20  per  cent,  of  an  increase  has  been  obtained 
and  in  some  cases  more  than  that  amount,  while  we  cannot,  from 
any  data  on  hand  at  present,  find  SLnywhere  as  great  an  increase 
as  20  per  cent,  in  fees  in  the  medical  profession. 


62 

The  Judicial  Council  of  the  American  Medical  Association, 
in  its  report  June  i6,  19 13,  among  other  things,  had  this  to  say: 

The  fees  therefore  of  the  physician  have  lagged  behind  those  of  the  surgeon 
and  the  worldly  rewards  in  internal  medicine  are  not  as  great  as  those  of 
surgery.  More  than  that,  the  rewards  given  to  physicians  are  on  the  average 
given  more  grudgingly  than  to  the  surgeon.  The  surgical  fees  are  enormously 
greater  than  they  were  twenty-five  years  ago;  medical  fees  still  remain  prac- 
tically the  same,  and  except  in  a  few  large  centers  have  hardly  advanced  at 
all.  Oftentimes,  especially  in  smaller  communities,  physicians  giving  their 
time,  draining  their  personalities,  giving  of  all  that  is  in  them,  find  that  the 
sense  of  obligation  to  reward  them  for  their  service  diminishes  in  direct  ratio 
as  a  feeling  of  friendship  from  their  patient  increases,  with  the  result  that 
they  cannot  collect  a  fee  for  an  honest,  difficult,  scientific  diagnosis  which 
results  in  the  life-saving  operation  for  their  patient,  while  the  surgeon  who 
does  the  mechanical  operation  readily  collects  a  relatively  large  fee. 

In  our  discussion,  therefore,  of  the  physician's  compensation 
as  applied  to  workmen's  compensation  acts,  we  feel  there  is  not 
a  just  increase  in  fees  obtained  as  compared  with  the  ordinary 
surgeon's  work  done  in  private  practice. 

Murray  N.  Hadley,  M.D.,  in  correspondence  to  the  Indiana 
State  Medical  Joiu-nal,  February,  19 16,  regarding  fees  under  the 
Workmen's  Compensation  Laws,  had  this  to  say: 

Anyone  giving  the  matter  unprejudiced  thought  will  soon  be  made  aware 
that  certain  questions  effecting  physicians  have  arisen  under  the  Workmen's 
Compensation  Law  that  are  very  difficult  of  solution.  As  might  be  expected 
the  question  of  fees  has  occupied  most  prominently  the  attention  of  physicians. 
This  is  entirely  proper,  for  unless  the  question  can  be  amicably  settled  it  will 
seriously  interfere  with  the  proper  working  of  the  Act. 

He  further  says: 

It  is  said  that  the  fees  are  too  small  and  without  doubt  in  some  instances 
they  are  and  should  be  revised,  but  no  one  has  said  what  they  should  be. 
We  have  no  data  on  which  to  base  a  schedule.  It  would  require  a  con- 
siderable amount  of  research  work  to  get  accurate  facts  relativ  to  the  average 
specific  fees  for  specific  services  rendered  the  industrial  class,  as  the  law 
provides  this  shall  be  the  basis  of  charge.  If  the  medical  profession  will 
produce  this  data  and  then  submit  it  to  the  liability  companies  and  they  re- 
fuse to  accept  it,  then  will  the  time  have  arrived  to  demand  it.  Let  no  one 
be  surprised,  however,  to  find  as  a  result  of  such  research  that  a  considerable 
amount  of  minor  surgical  services  rendered  the  industrial  class  under  the 
system  of  the  patient  paying  for  his  own  services  is  done  at  a  smaller  figure 
than  most  of  the  liability  companies'  schedules  call  for. 


63 

To  the  above  we  must  in  the  main  agree  that  antiquated  fee 
bills  of  twenty  years  ago  are  still  the  rule  and  are  in  vogue  in  the 
great  percentage  of  medical  societies  and  units  in  the  United 
States. 

It  is  also  without  dispute  that  fees  charged  to  patients  receiv- 
ing injuries,  which  now  come  under  the  compensation  laws  have 
been  paid  for  only  in  part  in  the  great  majority  of  instances  by 
the  laboring  classes;  while  under  the  present  business  arrange- 
ment the  payment  is  a  positiv  one  and  within  a  reasonable 
time. 

The  suggestion  also  made  in  the  above  quotation  would  offer 
an  incentiv  for  medical  societies  to  get  busy,  become  more  prac- 
tical business  men,  reduce  the  long  list  of  obsolete  fees  previously 
charged  to  a  modern  fee  basis,  proportionate  to  the  services  and 
sufficiently  intelligible,  so  that  it  can  be  a  basis  upon  which  lia- 
bility companies,  industrial  boards,  insurance  companies  and  the 
like  may  meet  us  upon  common  business  grounds. 

In  a  California  case  it  was  stated  that  the  reasonable  value 
of  medical  and  surgical  services  will  be  determined  with  refer- 
ence to  reasonable  and  usual  charges  by  physicians  for  services 
rendered  to  persons  of  the  earning  capacity  of  the  average  em- 
ploye affected  by  the  Compensation  Act,  namely,  an  employe 
with  an  average  earning  capacity  of  $1000  per  year. 

The  report  of  the  Industrial  Accident  Commission  of  the  State 
of  California  on  medical  payments  for  temporary  injuries,  says: 

In  the  cases  of  temporary  injury  it  seems  that  medical  organizations  run 
a  little  better  than  dollar  for  dollar;  $615,706.24  were  paid  out  for  temporary 
injuries  alone,  or  an  average  of  about  $19.06  per  case  considered.  (For  year 
1914.) 

During  a  comprehensiv  review  of  the  laws  in  the  32  states 
submitted  (as  shown  by  a  revised  table  of  amended  laws,  attacht), 
relativ  to  the  application  of  workmen's  compensation,  one  cannot 
help  but  be  struck  with  the  small  consideration  allotted  to  the 
medical  profession  in  their  application,  when  large  space  is  alloted 
to  almost  every  other  department,  amplifying  in  concise  terms 
the  various  minute  and  often  valueless  instructions,  as  compared 
to  the  vital  importance  of  medical,  surgical  and  hospital  aid  to 


64 

the  injured  person.  We  cannot  help  but  enlarge  upon  this  point 
when  we  feel  the  enormous  responsibility  placed  upon  the  medical 
and  surgical  profession  in  relation  to  the  injured  and  the  endeavor 
to  restore  to  normal  physical  condition  the  individuals  in  whose 
behalf  workmen's  compensation  laws  have  been  framed. 

Many  of  the  present  boards  in  various  states  assume  that  no 
fee  bill  is  necessary,  as  they  base  the  charges  upon  what  is  usually 
askt  by  physicians  and  surgeons  in  the  treatment  of  injuries  when 
the  individual  is  required  to  pay  the  same  in  general  practice. 

While  in  the  main  the  charges  of  the  average  physician  would 
be  legitimate,  honorable  and  just,  unless  some  system  is  adopted 
whereby  these  charges  shall  be  uniform,  as  well  as  equitable, 
it  is  evident  that  there  will  be  a  great  diversity  of  charges  sub- 
mitted for  similar  service,  together  with  the  length  of  time  re- 
quired to  produce  a  cure  and  return  to  work,  persons  receiving 
the  benefits  of  the  compensation  treatment. 

An  illustration  is  shown  by  a  chart  in  the  report  of  the  Industrial 
Accident  Commission  of  the  State  of  California,  which  chart 
shows  the  average  time  lost  per  case  by  character  of  medical 
treatment,  thus: 

Private  doctor  paid  a  specific  fee 20  days 

Medical  fees  not  specified  and  amounts  unknown 17  days 

Company  hospital  or  contract  doctor 15  days 

No  medical  fees  reported  as  paid 12  days 

This  shows  that  there  is  a  tendency  at  times  on  the  part  of  the 
doctor  attending  patients  in  private  capacity  to  carry  along  the 
individual  past  the  time  when  he  might  return  to  his  occupation 
and  especially  if  he  were  directed  under  a  system  of  workmen's 
compensation  as  carried  out  under  systematic  medical  regulation. 

It  is  quite  probable  that  in  cases  of  men  of  higher  calling  and 
receiving  a  larger  salary  than  that  determined  by  the  law,  viz., 
$1000  per  year,  would  desire  more  expensiv  medical,  siu-gical 
and  hospital  treatment  and  attention  on  the  part  of  the  surgeon, 
but  the  law  fixes  the  compensation,  basing  it  only  upon  one 
fixt  income;  therefore  employes  desiring  more  expensiv  hospital 
and  surgical  services  should  consider  that  any  additional  expenses 
must  be  borne  by  themselves. 


65 

From  a  composite  view-point  of  the  laws  in  all  the  states  now 
having  workmen's  compensation  and  fee  bills  submitted  by  com- 
pensation boards,  we  find  that  the  minimum  fee  as  usually  charged 
in  the  community  i  the  basis  of  payment  to  physicians  doing 
compensation  work;  and  in  most  of  the  cases,  while  the  fee  is 
often  below  that  which  may  be  at  times  obtained  in  a  like  com- 
munity were  the  patient  paying  for  such  services,  there  come 
times  when  every  reasonable  medical,  surgical  and  hospital 
treatment  could  not  be  afforded  on  the  part  of  the  surgeon  for  the 
amount  granted  in  the  law,  as  many  cases  of  severe  nature  re- 
quire extraordinary  care,  attention  and  skill;  and  as  a  result  we 
would  make  this  observation  when  new  legislation  is  contemplated, 
in  our  capacity  as  recommenders — that  states  should  amend 
their  various  acts  and  give  more  discriminary  power  to  the  com- 
missioners, boards,  or  different  executiv  departments  applying 
the  law,  in  extraordinary  conditions  of  the  patients  that  the  sur- 
geons might  be  allowed  to  expend  more  for  medical,  surgical 
and  hospital  treatment,  thereby  rendering  greater  aid  in  these 
serious  cases. 

In  nearly  all  of  the  compensation  acts  reference  is  made  to 
hospitals,  as  well  as  to  medical  and  surgical  aid.  We  feel  that 
this  combination,  while  necessary  to  work  in  conjunction  with 
each  other,  should  be  separated  so  far  as  compensation  is  con- 
cerned, as  many  of  the  laws  make  such  statements  in  the  applica- 
tion of  the  remuneration  that  it  is  difficult  to  separate  medical 
and  surgical  treatment  from  the  hospital  fee,  thereby  offering  an 
opportunity  for  disagreement  and  argument  as  to  the  placing 
the  fee. 

Many  of  the  commissioners  in  their  discussion  of  the  applica- 
tion of  stu-gery  to  injured  employes,  make  reference  to  the  X-ray 
and  it  is  the  consensus  of  opinion  that  the  X-Ray  Department 
is  separate  from  compensation  granted  for  medical  and  surgical 
attention.  It  is  wise  that  this  is  so,  as  it  is  found  that  X-Ray 
charges  would  materially  eat  up  the  amount  allowed  in  any  case, 
leaving  but  little  for  the  surgeon  to  receive  at  the  expiration 
of  the  one,  two  or  more  weeks,  according  to  the  various  laws. 

A  point  of  advantage,  it  would  seem  to  us,  in  conducting  a 


66 

surgical  case  due  to  traumatism  and  coming  under  workmen's 
compensation  laws,  is  the  fact  that  the  patient  in  the  majority 
of  the  laws  is  placed  directly  under  the  charge  of  the  attending 
surgeon  and  must  submit  to  what  is  deemed  proper  treatment 
in  a  given  injury.  The  employe's  refusal  to  obey  the  advice 
given  by  the  surgeon  vitiates  the  employe's  chances  to  recover 
only  such  compensation  as  he  would  be  entitled  to  receive  had  he 
submitted  to  treatment  and  had  the  treatment  proven  normally 
successful.  As  a  result  of  this  submission  on  the  part  of  the  em- 
ploye the  recovery  is  more  prompt,  as  instructions  are  carried 
out  in  a  more  definit  and  efficacious  manner. 

The  question  of  operation  as  recommended  by  the  surgeon  en- 
tails a  point  of  personal  submission  on  the  part  of  the  employe 
and  a  necessity  to  submit  to  a  reasonable  operation  when  a  chailce 
of  recovery  is  thereby  considered.  If,  however,  the  employe 
is  advised  to  submit  to  a  serious  major  operation,  which  would 
vitiate  his  chances  of  recovery,  or  be  a  risk  of  life  were  he  to  sub- 
mit, the  Supreme  Court  of  Michigan  has  held  that  the  employe's 
refusal  to  submit  to  an  operation  of  that  kind  is  not  unreasonable. 

In  the  application  of  the  medical,  surgical  and  hospital  sec- 
tions of  compensation  acts,  the  question  has  been  raised  that 
surgeons  working  under  compensation  laws  endeavor  to  over- 
charge. These  statements  have  been  proven  false  in  the  greater 
majority  of  cases. 

The  report  of  the  Judicial  Council  of  the  American  Medical 
Association,  among  other  things,  has  this  to  say: 

That  a  few  of  the  profession  have  greedily  endeavored  to  obtain  more  than 
they  deserved,  is  undoubtedly  true,  and  any  referee  board  of  physicians  or 
surgeons  to  which  these  claims  have  been  referred,  has  been  the  first  to  con- 
demn the  excessiv  amounts  claimed.  There  is  no  question  that  public 
opinion  among  the  medical  profession  condemns  overcharging  the  state  or 
overcharging  for  this  industrial  work  as  severely  as  it  condemns  any  other 
dishonest  practice  perpetrated  by  the  members  of  the  profession. 

It  is  a  well-known  fact  that  there  is  a  tendency  for  all  corpora- 
tions and  industrial  insurance  companies,  when  a  state  begins  the 
operation  of  workmen's  compensation  laws,  to  make  application 
to  members  of  the  profession  in  every  industrial  locality,  whereby 
they  may  obtain  medical  and  surgical  service  for  injured  workers, 


67 

and  that  contracts  are  requested  of  these  men,  many  of  them 
at  the  lowest  rate  that  can  be  obtained,  and  as  a  consequence 
doctors  will  engage  in  contract  services  and  such  service  is  over- 
workt,  with  the  result  that  economic  conditions  are  against  the 
best  interests  of  those  who  employ  such  contract  surgeons,  by 
reason  of  hasty  method  of  treatment,  carelessness  in  following 
aseptic  methods,  limiting  the  time  to  each  individual  patient, 
bringing  such  results  as  are  stated  by  the  Judicial  Council,  thus : 

It  is  often  noticeable  that  pus  and  politics  go  together,  and  he  who  shaves 
the  medical  fee  piles  up  compensation  expenses,  A  stingy  man  hires  a  poor 
surgeon  and  begets  many  infections  and  much  disability. 

Workmen's  compensation  acts  have  raised  a  new  question  that, 
while  not  from  the  view-point  of  income  to  the  surgeons,  is  one 
that  must  be  rated  as  a  commercial  asset  in  applying  the  provi- 
sions of  the  compensation  acts,  namely,  the  new  standards  of 
surgical  and  hospital  efficiency,  as  they  apply  to  the  recovery 
of  the  patient  and  his  working  economic  value.  We  are  quite 
sure  that  a  patient  coming  under  a  compensation  act,  when  treated 
by  a  competent  surgeon,  with  the  end  in  view  to  place  back  into 
the  industrial  world  such  patient,  with  the  least  possible  effect 
of  injury,  as  far  as  working  ability  is  concerned,  gives  a  new 
impetus  to  that  sm-geon  to  do  for  his  patient  all  that  human  flesh 
and  blood  can  do,  and  to  this  end  the  question  of  relationship 
of  surgeon  and  hospital  is  very  pertinent.  It  is  this  question  of 
hospital  service  and  attending  physician  that  has  stirred  much 
comment  in  many  of  the  states  having  compensation  acts  for 
many  years  and  we  doubt  not  that  revised  plans  for  compensa- 
tion, proportionate  to  work,  will  soon  follow,  as  it  is  very  conclu- 
siv  that  cheap  work  and  cheap  service  do  not  bring  good  results. 
The  underpaid  hospital,  so  far  as  workmen's  compensation  acts 
are  concerned,  is  brought  out  very  nicely  in  the  first  annual  re- 
port of  the  Board  of  Compensation  Commission  of  Connecticut, 
which  says : 

If  the  spirit  underlying  this  act  is  to  make  each  industry  carry  the  expense 
of  the  casualties  that  occur  in  the  conduct  of  that  business,  it  fails  to  do  so 
when  the  hospitals  and  physicians  are  forced  to  care  for  them  at  a  loss  or  as 
charity  cases.  It  costs  the  hospitals  from  $io  to  $15  per  week  to  care  for 
cases.     If  the  compensation  cases  are  placed  in  public  wards  at  $7  per  week. 


68 

the  balance  has  to  be  made  up  by  contributions  that  are  made  for  charity, 
and  physicians  should  not  be  askt  to  treat  these  cases  for  nothing  in  hospitals 
any  more  than  they  are  askt  to  treat  them  outside  for  nothing. 

Advantages  of  Social  Insurance  against  Accidents    under    Work- 
men's Compensation  Laws. 
First. — To  Workmen. 

The  benefits  of  workmen's  compensation  laws  as  applied  to 
the  working  classes  of  the  United  States  cannot  be  measured  in 
dollars  and  cents.  These  laws  were  never  made  with  the  idea  of 
compensating  disabled  workmen  or  working  women  to  the  extent 
that  they  shall  be  supported  entirely  from  these  funds  while  dis- 
abled by  accident,  but  it  is  to  be  supposed  that  they  are  for  the 
purpose  of  tiding  over  a  most  difficult  time  in  their  lives  when, 
in  an  unguarded  moment,  an  accident  befalls  them,  suddenly 
removing  them  from  their  daily  toil  and  the  income  which  it 
brings.  Any  social  insurance  scheme  which  would  be  sufficiently 
large  to  maintain  the  injured  employe  would  be  too  great  for  in- 
dustry to  bear  and  it  would  be  the  basis  of  much  trouble  among 
this  class  of  our  people,  as  we  often  find  a  great  tendency  to  seek 
even  greater  benefits  than  the  law  gives,  whether  it  be  partial 
indemnity  or  a  sufficient  amount  which  would  render  it  attractiv ; 
consequently  every  law  in  its  application  takes  into  considera- 
tion the  immediate  relief  of  the  physical  fault  by  supplying 
"seasonably,"  or  as  some  term  it  "as  and  when  needed"  medical, 
surgical  and  hospital  services. 

Another  benefit  which  these  laws  give  to  the  working  classes, 
is  that  prompt  service  is  rendered  them  and  in  the  great  majority 
of  cases  we  doubt  not  that  the  best  service  possible  to  be  ob- 
tained is  rendered,  thereby  giving  them  the  advantage  of  speedy 
return  to  normal  health,  where  such  a  thing  is  possible. 

Under  ordinary  conditions,  the  average  person  in  the  working 
world  delays  in  sending  for  a  medical  attendant,  hoping  and  trust- 
ing that  kind  nature  will  repair  the  damages,  thereby  saving 
them  an  additional  expense.  Often  this  delay  is  the  most  serious 
thing  which  they  could  have  attempted,  as  traumatism  destroy- 
ing continuity  of  structure,   allowing  infection  to  take  place. 


69 

renders  the  treatment  and  cure  of  the  injury  many-fold  greater 
than  where  prompt  scientific  surgical  principles  are  applied. 

Further,  workmen's  compensation  acts,  after  the  waiting  period, 
give  to  those  people  that  which  in  former  times  was  denied  them 
except  by  process  of  law,  namely,  a  sufficient  amount  of  money 
to  enable  them  to  live  without  starvation  or  fear  of  absolute 
want.  Industrial  communities  in  years  gone  by  were  frequently 
destitute  of  modern  hospital  facilities,  but  with  the  ever-growing 
idea  of  humanitarianism  which  now  pervades  the  minds  of  those 
who  govern  the  financial  world,  modem  hospitals  have  come  into 
existence  and  opened  their  doors,  first  to  the  poor  of  the  community 
and  later  to  those  who  come  under  the  compensation  provision. 
In  these  modern  homes  for  the  care  of  the  sick  and  injured,  quicker 
restitution  of  health  in  a  great  majority  of  instances  is  obtained. 

Every  law,  so  far  as  we  have  been  able  to  observ,  specifically 
states  that  injuries  caused  thru  intoxication  are  barred  from  com- 
pensation, and  it  would  seem  that  if  there  is  a  benefit  to  be  ob- 
tained the  moral  effect  of  this  law  to  render  sober  the  working 
classes  is  by  no  means  a  small  item. 

We  are  often  prone  to  consider  personal  liberty  a  great  factor 
in  selecting  competent  medical  attendance  and  our  conduct 
during  sickness  or  injury  in  relation  to  the  advice  of  physicians 
who  are  caUed  to  render  aid.  Applied  to  the  working  people  this 
often  is  much  to  their  detriment,  because  they  are  not  always 
competent  to  judge  who  are  best  fitted  to  treat  them,  especially 
in  cases  of  injury,  and  when  treated  as  private  patients  take  ad- 
vantage of  the  medical  attendants'  directions,  doing  many  things 
which  deter  their  chances  for  prompt  recovery  to  a  much  longer 
period  than  were  they  under  direct  supervision  of  competent  surgical 
service,  which  holds  them  directly  responsible  for  every  act  in 
compliance  with  carrying  out  the  directions  for  their  relief. 

Many  of  the  laws  distinctly  state  that  while  it  is  the  employer's 
duty  to  furnish  "reasonable  medical,  surgical  and  hospital  treat- 
ment," it  is  equally  as  necessary  that  the  employe  submit  strictly 
to  the  advice  given  by  the  physician  or  surgeon  in  the  treatment 
of  his  injury,  and  it  has  been  proven  that  the  time  to  reliev  and 
cure  has  been  reduced  materially  in  this  manner. 


70 

Malingering  can  never  be  entirely  overcome,  but  it  is  much 
easier  to  reach  and  remove  when  the  patient  is  observed  by- 
physicians  who  receive""  their  compensation  thru  insurance  asso- 
ciations, rather  than  from  the  individual  himself,  and  in  that 
manner  the  wheels  of  industry  are  not  prevented  from  turning 
by  the  loss  of  the  worker,  who  would  make  himself  a  drone  rather 
than  the  busy,  energetic  individual  whom  we  so  much  admire. 

Second. — To  Physicians. 

While  it  is  necessary  for  us  in  this  discussion  to  consider  the 
features  of  workmen's  compensation  acts  largely  in  their  effect 
upon  the  physicians'  recompense,  yet  we  believe  that  there  is  a 
sense  of  satisfaction  in  watching  a  patient,  who  has  been  injured, 
respond  to  treatment  and  rapidly  recover  his  usefulness  thru 
our  efforts,  when  we  have  carried  out  every  wish  in  his  behalf, 
so  far  as  treatment  is  concerned,  and  the  pleasure  which  the 
medical  profession  has  so  often  taken  unto  itself,  that  of  restoring 
the  broken  and  injured  human  frame.  We  certainly  should  con- 
sider workmen's  compensation  laws  as  applied  to  siu-geons  in 
that  branch  of  work  as  a  great  advantage.  We  cannot  deny  the 
fact  that  workmen's  compensation  laws  do  not  allow  of  any  ex- 
travagance in  the  nature  of  supplies  and  yet  when  we  look  back 
in  the  past  and  realize  what  many  of  the  earlier  pioneers  of  surgery 
used  in  the  treatment  of  the  injured  and  with  a  fair  degree  of 
success,  we  must  often  consider  our  methods  as  somewhat  ex- 
travagant. 

Another  advantage  to  the  physician  in  the  treatment  of  acci- 
dent cases  under  workmen's  compensation  laws  is  the  well  ac- 
knowledged fact  that  those  who  employ  us  as  surgeons  for  their 
work  are  prompt  in  paying  for  our  services.  In  contrast  to  this, 
we  find  a  somewhat  varied  percentage  of  amounts  collected  in 
the  average  practice,  basing  the  loss  of  collections  from  lo  per  cent, 
to  50  per  cent.,  and  it  has  been  stated  that  in  Massachusetts 
it  has  been  found  that  after  two  weeks  when  the  industrial  acci- 
dent board  ceased  to  pay  hospital  fees  for  the  injured  workmen, 
it  was  impossible  to  collect  from  patient  or  friends  any  further 
monies  for  hospital  services  in  from  50  per  cent,  to  90  per  cent. 


71 

of  cases.  It  is  doubtful  if  the  experience  of  physicians  has  varied 
much  from  this  experience  of  hospitals. 

This  condition  of  affairs  without  doubt  exists  thruout  the  coun- 
try and  the  greatest  trouble  experienced  by  the  average  medical 
man  in  his  every  day  work,  especially  in  surgical  work  of  the  ac- 
cident type,  is  recovering  legitimate  fees.  It  has  been  stated 
that  there  is  a  tendency  to  criticize  the  cost  of  medical  services 
under  the  compensation  laws  in  the  various  states  and  that  the 
income  of  physicians  is  in  some  instances  "dollar  for  dollar" 
paid  to  the  employe  in  compensation ;  while  in  others  it  is  variously 
stated  from  35.4  per  cent,  to  58  per  cent,  of  what  would  have 
been  the  fee  under  the  regular  charge  for  a  like  case  in  general 
practice. 

Another  item  of  importance  relativ  to  the  collection  of  fees 
under  compensation  acts  is  one  that  is  somewhat  diversified  in 
the  thirty-one  states  considered.  In  the  Bulletin  of  the  Industrial 
Commission  of  Ohio,  October  ist,  19 14,  is  the  following: 

Against  whom  is  the  physicians'  account?  It  should  be  remembered 
that  the  law  implied  specifically  that  all  awards  were  to  be  paid  to  the  in- 
jured workman.  This  impliedly  respects  the  right  of  the  workman  to  select 
his  attending  physician  and  the  allowance  to  be  made  therefor  from  the 
fund  cannot  be  logically  a  question  of  dispute  between  the  commission  and 
the  physician,  the  physician  making  his  charge  against  the  injured  workman 
with  the  idea  of  collecting  it;  the  employer  paying  his  premium  based  on  an 
industrial  accident  basis,  and  industrial  conditions,  with  the  idea  of  the 
premium  being  for  the  purpose  of  paying  it,  etc. 

It  would  seem  that  this  feature  of  applying  the  method  of 
payment  is  much  that  would  be  in  favor  of  the  compensation 
boards  and  the  employer  and,  while  in  the  main  the  fee  earned 
by  the  surgeon  would  reach  its  particular  destination,  yet  we 
cannot  doubt  it  would  in  many  cases  lead  to  a  controversy, 
when  some  time  had  elapsed  after  the  case  had  been  settled  and 
the  employe  forgetting  or  neglecting  to  pay  his  bill. 

A  business  feature  of  compensation  acts  is  essential,  whether 
the  bill  is  paid  by  the  employer  or  employe  and  the  suggestion 
is  made  that  on  several  occasions  commissions  have  commented 
on  the  poor  business  ability  of  our  profession  in  not  rendering 
prompt  accounts  for  services  rendered.     We  cannot  help  but  see 


72 

the  necessity  of  placing  the  payment  of  all  compensation  directly 
up  to  the  employer  or  insurer. 

The  question  of  the  limit  of  aid  often  involves  the  question 
of  first  aid  and  subsequent  attendance  and  it  has  been  my  ob- 
servation that  a  difference  has  arisen  in  the  minds  of  many  com- 
missioners as  to  the  necessity  of  too  frequent  visits  and  too  fre- 
quent dressings. 

Obviously  the  time  is  not  far  distant  when  the  siurgical  instruc- 
tion and  experience  in  industrial  cases  must  be  brought  to  a 
higher  standard  of  proficiency  and  that  surgeons  undertaking 
this  branch  of  work  must  study  the  economic  side  from  the  view 
of  the  compensation  laws,  as  well  as  the  nature  of  income  which 
he  is  to  receiv  from  such  compensation  work.  Over-zealous  ap- 
plication to  the  patient  in  the  nature  of  too  frequent  dressings, 
too  frequent  visits  and  over  meddlesomeness,  while  they  in- 
crease the  number  of  visits  and  proportionately  the  income, 
must  be  criticized  to  the  extent  that  such  bills  are  frequently  re- 
duced when  presented  to  commissioners  or  insurance  companies 
for  final  payment. 

The  joint  relationship  of  major  surgical  operations,  which  are 
smaller  in  number  in  accidental  surgery  in  comparison  to  minor 
surgery,  suggests  the  observation  that  laws  in  some  states  give 
the  fee  bill  in  major  surgery  as  including  the  operation  and  sub- 
sequent treatment,  while  in  minor  surgery  it  offers  the  first  aid 
and  subsequent  dressings,  and  that  some  commissioners  would 
be  pleased  to  have  the  entire  matter  arranged  under  operation 
and  subsequent  attendance  included  on  a  flat  fee  basis.  It  can 
readily  be  seen  that  no  matter  how  much  we  argue  pro  and  con 
we,  as  medical  men,  must  come  to  some  definit  understanding 
thruout  the  entire  Union  as  to  a  better  basis  of  charging  for  our 
work. 

Summary. 

Workmen's  compensation  laws  are  here  to  stay.  They  are  of 
immense  benefit  to  the  industrial  community  when  properly 
drawn  and  properly  applied.  To  the  medical  profession,  from 
the  point  of  effecting  the  physicians'  recompense,  they  have  the 
advantage   of   certainty  of  payment,  a  fair  degree  of  continued 


73 


service  thniout  the  year,  offering  an  opportunity  to  take  indus- 
trial accident  work  and  at  the  same  time  carry  on  the  usual  every- 
day practice,  especially  in  smaller  communities  where  not  under 
specific  contract  by  corporations.  This  method  of  compensation 
under  industrial  laws  tends  to  offer  the  opportunity  to  specialize 
and  become  more  proficient  on  the  part  of  those  desiring  to  under- 
take this  class  of  work. 

A  better  understanding  of  the  law  in  each  individual  state, 
under  which  the  physicians  and  sm-geons  are  working,  will  have 
a  tendency  to  make  possible  a  better  compliance  with  the  law 
and  as  a  result  have  harmonious  work  establisht  between  the 
commission  or  board  applying  the  law  and  the  physicians  of  that 
state,  and  wherever  unity  among  the  physicians  of  the  state  is 
establisht  legislativ  co-operation  must  and  will  be  brought  about. 

Compensation  Laws  as  Applied  to  Medical,  Surgical  and  Hospitav 

Service. 
Revised  Table  as  Obtained  from  Amended  Laws  from  Report  of  Commissions 
Obtainable  to  May,  iqi6. 

Medical  and  surgical  compensation  is  paid  only  if 
employe  dies,  leaving  dependents.  If  workman  leaves 
no  widow,  children  or  dependents,  reasonable  expense  of 
medical  attendance  shall  be  paid. 

No  provision  is  made  for  medical,  sm-gical  or  hospital 
payment  under  the  law. 

Such  medical,  surgical  and  hospital  treatment,  includ- 
ing nursing,  medicines,  medical  and  surgical  supplies, 
crutches  and  apparatus  as  may  be  reasonably  required 
at  time  of  injury  and  within  90  days  thereafter. 

Must  furnish  medical,  surgical  and  hospital  treatment, 
medicines  and  surgical  supplies,  crutches,  and  apparatus 
for  a  period  not  exceeding  30  days  and  $100  in  value. 

Employer,  as  soon  as  he  has  knowledge  of  injury,  shall 
provide  a  competent  physician  or  surgeon  to  attend  the 
injured  employe,  and  in  addition  shall  furnish  such  medi- 
cal and  surgical  aid  or  hospital  service  as  such  physician 
or  surgeon  shall  deem  reasonable  or  necessary. 

Charges  limited  as  prevail  in  community  to  similar 
treated  persons  of  like  standard  of  living  when  such 
treatment  is  paid  for  by  the  injured  persons. 


Arizona. 


California. 


Colorado. 


Connecticut. 


74 


Illinois. 


Indiana. 


Iowa. 


Kansas. 


Louisiana. 


Maine. 


Maryland. 


Massachusetts. 


Missouri. 


Michigan. 


Employer  shall  provide  necessary  first  aid  medical, 
surgical  and  hospital  service  for  a  period  not  longer  than 
8  weeks,  not  to  exceed  $200. 

The  period  of  medical  and  surgical  aid  is  extended  for 
30  days. 

No  data  obtained  as  to  amount  of  compensation 
allowed. 

At  any  time  after  an  injury  and  until  the  expiration 
of  two  weeks,  the  employer,  if  so  requested  by  the  work- 
man, or  any  one  for  him,  or  if  so  ordered  by  the  court  or 
Iowa  Industrial  Commissioner,  shall  furnish  reasonable 
surgical,  medical  and  hospital  services  and  supplies,  not 
exceeding  $100. 

Compensation  paid  only  if  employe  dies,  leaving  no 
dependents,  not  to  exceed  $100,  which  shall  include  burial 
expenses. 

Medical  and  surgical  aid  fumisht  for  first  14  days,  not 
to  exceed  in  amount  $100. 

Maximum  $30  for  first  two  weeks,  which  includes 
reasonable  medical  and  hospital  services  and  medicine; 
in  case  of  major  surgical  operation  additional  cost  is 
arranged  between  employer  and  employe. 

Such  medical,  surgical  or  other  attendance  or  treat- 
ment, nurse  and  hospital  services,  medicines,  crutches  and 
apparatus  as  may  be  required  by  the  commission,  not  to 
exceed  $150. 

If  employe  leaves  no  dependents,  reasonable  expense 
of  last  sickness,  which  shall  not  exceed  $200,  (Burial 
expenses  included  in  this  amount.)  Massachusetts  has 
no  fee  bill,  the  amount  being  paid  as  is  usual  for  case 
of  like  condition  when  paid  by  employe. 

Liability  of  the  employer  for  medical  aid  unlimited 
and  in  case  he  fails  to  furnish  or  tender  the  same,  the 
employe,  or  some  one  for  him,  may  make  the  employer 
liable  therefor. 

Requires  employer  to  pay  for  hospital  service  in  public 
institution. 

Limits  all  charges  for  medical  aid  to  such  as  are  reason- 
able. 

During  first  three  weeks  after  injury  the  employer 
shall  furnish,  or  cause  to  be  fumisht,  reasonable  medical 
and  hospital  services  and  medicines  when  they  are  needed. 


Minnesota. 

Montana. 
Nebraska. 

Nevada. 

New  Hampshire. 

New  Jersey. 
New  York. 


Ohio. 


Oklahoma. 


Oregon. 


Pennsylvania. 


75 


Medical  and  surgical  treatment,  medical  and  surgical 
supplies,  crutches  and  apparatus,  not  to  exceed  90  days, 
to  the  amount  of  $100,  except  by  order  of  court  upon 
necessity  being  shown,  shall  furnish  additional  service 
not  to  exceed  $200. 

Medical  and  surgical  compensation  paid  to  amount 
of  $50  for  period  of  two  weeks. 

During  first  21  days,  reasonable  medical  and  hospital 
services  and  medicines,  not  to  exceed  $200, 

If  employe  leaves  no  dependents  of  any  kind,  expenses 
of  his  last  sickness  and  burial  shall  be  paid,  not  to  exceed 
the  sum  of  $125. 

None. 

Compensation  adjusted  between  employer  and  em- 
ploye. 

First  two  weeks  reasonable  medical  and  hospital  ser- 
vices and  medicines  as  and  when  needed,  not  to  exceed 
$50  in  value,  unless  employe  refuses  to  allow  them  to  be 
fumisht  by  the  employer. 

Medical,  surgical  and  hospital  service,  nurse,  medicines, 
crutches  and  apparatus  fumisht  during  60  days  after 
injury;  fees  and  other  charges  for  treatment  regulated 
by  commission  and  limited  to  such  charges  as  prevail 
in  the  same  community  for  similar  treatment  of  injured 
persons  of  a  like  standard  of  living. 

Medical,  nurse  and  hospital  services  and  medicine, 
not  to  exceed  the  sum  of  $200  in  any  instance. 

The  Board  has  power  to  regulate  the  furnishing  of 
medical  nurse  and  hospital  services  to  injured  employes 
entitled  thereto  and  for  the  payment  therefor. 

The  period  of  compensation  granted  is  15  days. 
Amount  granted  for  medical,  surgical  and  hospital  ser- 
vices not  obtained. 

Medical  and  surgical  attendance  and  hospital  accom- 
modation, not  to  exceed  $250  in  any  one  case. 

Surgeons'  industrial  fee  bill  regulates  charges  to  be 
made. 

Medical,  surgical  and  hospital  services  provided  for 
first  14  days  after  injury,  not  to  exceed  in  amount  $25; 
except  if  major  surgical  operation  is  necessary,  when 
$75  is  allowed. 


76 


Rhode  Island. 


Texas. 


Vermont. 


Washington. 


West  Virginia. 


Wisconsin. 


Reasonable  medical  and  hospital  service  and  medi- 
cines when  needed  provided  for  period  of  2  weeks,  but 
Rhode  Island  has  no  law  fixing  fee  bills  for  physicians 
under  Workmen's  Compensation  Act. 

During  first  week  of  injury,  Association  shall  furnish 
reasonable  medical  aid,  hospital  services  and  medicines 
when  needed,  and  if  it  does  not  furnish  these  immediately 
as  and  when  needed  it  vshall  repay  all  sums  reasonably 
paid  or  incurred  for  same. 

Medical,  surgical  and  hospital  services  fumisht  for 
first  14  days,  not  to  exceed  in  amount  $75. 

None. 

First  aid  bill  will  be  voted  on  at  the  next  general  elec- 
tion and  if  bill  passes  a  fee  bill  will  undoubtedly  be 
adopted. 

At  present  no  first  aid  or  medical  attention  provision 
in  the  Washington  Workmen's  Compensation  Act. 

Such  sums  for  medical,  surgical  and  hospital  treat- 
ment as  may  reasonably  be  required,  in  any  case  not  to 
exceed  $150;  provided  in  case  of  permanent  disability 
that  said  disability  can  be  reduced  by  surgical  or  medical 
treatment,  the  amount  expended  for  medical,  surgical  or 
hospital  treatment  shall  not  exceed  $300. 

Medical,  surgical  and  hospital  treatment,  medicines, 
medical  and  surgical  supplies,  crutches  and  apparatus  for 
period  not  to  exceed  90  days. 


HEALTH  INSURANCE. 

By  John  B.  Andrews,  Ph.D.,  New  York,  Secretary  American  Association  for  Labor 

Legislation. 

Medicine  has  progrest  far  since  doctors  taught  that  the  in- 
flammation from  a  burn  could  be  reUeved  by  holding  the  af- 
fected part  near  a  hot  fire,  and  that  the  bruised  head  of  a  viper 
would  cure  snakebite.  Knowledge  and  technique  have  abund- 
antly progrest,  but  the  pivotal  change,  I  take  it,  has  been  the 
development  of  the  scientific  spirit.  When  Vesalius  refused  to 
hark  back  to  authority  for  his  theories,  but  appealed  directly  to 
the  facts,  guesswork  and  traditionalism  lost  respectability,  and 
genuine  research  took  their  place.  In  the  difiicult  field  where 
medicine  and  sociology  meet,  the  American  Academy  of  Medi- 
cine has  well  upheld  this  ideal. 

I  feel  at  home  in  meeting  you  for  this  discussion  because  the 
organization  I  represent  also  approaches  its  problems  in  a  scien- 
tific spirit.  We  endeavor  to  apply  scientific  methods  to  the  sub- 
ject of  labor  organization.  We  endeavor  to  base  our  action  on 
careful  study  of  experience.  The  scientific  attitude  also  im- 
plies that  we  must  consider  the  welfare  of  the  whole  country, 
for  the  future  as  well  as  for  the  present. 

Perhaps  the  best  evidence  that  we  have  succeeded  in  main- 
taining a  scientific  attitude  toward  labor  problems  is  that  we  are 
occasionally  criticised  by  employers  as  being  too  friendly  to 
trade  unions  and  again  just  as  roundly  condemned  by  certain 
representatives  of  labor  as  being  too  friendly  to  the  employers. 

The  subject  of  our  discussion  is  Health  Insurance,  with  special 
reference  to  the  model  bill  prepared  by  the  Association  for  Labor 
Legislation.  Perhaps  I  cannot  do  better  in  the  beginning  than 
explain  to  you  why  and  how  we  drafted  this  legislation. 

About  seven  years  ago,  you  will  remember,  we  began  to  give 
serious  attention  to  workmen's  compensation  for  industrial 
accidents.  Investigations  indicated  that  no  fewer  than  25,000 
human  lives  were   sacrificed   each  year  in  American  industry. 


78 

The  list  of  serious  injuries,  incapacitating  for  a  period  of  four 
weeks,  or  more,  totalled  about  700,000.  Bach  year  of  productiv 
endeavor  yielded  as  an  incidental  product  some  45,000  widows 
and  orphans.  This  truly  was  a  social  problem  worthy  of  our 
best  remedial  efforts. 

The  coming  of  workmen's  compensation,  which  in  the  short 
space  of  six  years  swept  over  35  of  our  50  states  and  territories, 
and  over  the  federal  government  for  its  own  employes,  was 
revolutionary  in  its  effects.  Accident  statistics  suddenly  be- 
came something  more  than  a  sorry  joke.  Information  accumu- 
lated almost  automatically.  Millions  of  dollars,  formerly  spent 
in  wasteful  and  contentious  methods,  were  now  available  to 
care  for  the  victims  of  accidents  on  a  systematic,  scientific  basis. 
Even  those  who  in  the  beginning  opposed  workmen's  compensa- 
tion as  a  legislativ  proposal  are  now  loyal  adherents  of  it  in  prac- 
tice. Both  employes  and  employers  as  well  as  society  in  gen- 
eral have  benefited.  And  perhaps  the  chief  gain  has  been  the 
continuous  economic  pressure  toward  accident  prevention. 
Many  employers,  in  cooperation  with  their  employes  and  the 
agents  of  the  state,  are  now  preventing  from  one-half  to  two- 
thirds  of  their  accidents  which  six  years  ago  they  regarded  as 
inevitable.  The  coming  of  workmen's  compensation  gave  im- 
petus to  the  great  movement  for  "Safety  First." 

As  early  as  1912  it  had  become  evident  to  many  people  that 
this  social  insurance  method  of  dealing  successfully  with  indus- 
trial accidents  would  be  extended  before  many  years  to  another 
and  no  less  serious  contingency  in  the  life  of  the  worker.  At  the 
annual  meeting  of  the  Association  for  Labor  Legislation,  held 
in  Boston  that  year,  a  national  committee  was  provided  to  in- 
vestigate the  subject  of  workingmen's  sickness.  The  members 
of  that  committee  include  leading  authorities  of  the  country  on 
statistics,  medicine,  nursing,  and  social  insurance. 

EXTENT  AND   COST   OF   SICKNESS. 

The  committee  found  that  about  3,000,000  persons  in  the 
United  States  are  sick  at  any  one  time,  and  that  each  of  our 
30,000,000    wage-earners    loses    an    average    of    approximately 


79 

nine  days'  work  from  this  cause  yearly,  while  the  resultant 
yearly  wage  loss  totals  $500,000,000  and  medical  treatment 
costs  an  additional  $180,000,000  annually. 

This  estimate  of  nine  days'  illness  for  each  wage-earner  is  sub- 
stantiated b}^  the  recent  community  sickness  surveys  carried 
out  by  the  Metropolitan  Life  Insurance  Company  in  Rochester, 
N.  Y.,  and  Trenton,  N.  J.,  which  revealed  an  average  of  8.5 
days  of  disability  a  year  for  men  and  9 . 4  days  for  women. 

The  enormous  expenditure  of  $180,000,000  a  year  for  med- 
ical care  cannot  be  met  by  our  industrial  sick.  An  analysis 
made  by  the  Boston  Dispensary  showed  that  only  17  per  cent, 
of  the  families  with  which  the  institution  was  in  touch  received 
incomes  from  which  they  should  be  expected  to  pay  for  medical 
treatment  beyond  that  necessary  in  childbirth  and  acute  illness 
in  the  home.  In  the  Rochester  survey  it  was  found  that  39 
per  cent,  of  those  who  were  sick  had  no  physician  in  attendance; 
of  those  who  were  ill  but  able  to  work,  54.7  per  cent,  had  no 
physician.  In  New  York  State,  out  of  300,000  patients  cared 
for  by  185  hospitals,  46  per  cent,  were  taken  as  public  charges 
or  as  free  patients.  In  New  York  City  alone,  forty-six  hospitals 
cared  in  one  year  for  69,000  patients,  or  57  per  cent,  of  their 
total,  who  paid  nothing  for  their  treatment.  Yet  the  United 
Hospital  Fund  states  that:  "At  present  only  one  in  ten  persons 
seriously  ill  or  injured  in  this  city  now  gets  treated  in  any  hospi- 
tal. For  lack  of  proper  treatment  thousands  lose  their  health 
and  efficiency  and  become  a  burden  to  their  friends  and  the  com- 
munity." Even  the  dispensaries  of  New  York,  with  their  4,500,000 
treatments  yearly,  fail  to  reach  all  of  those  who  require  their 
services. 

Wage  studies,  furthermore,  show  that  the  slender  savings 
of  workingmen  are  inadequate  to  meet  the  wage  loss  due  to 
sickness.  A  recent  investigation  of  700  sick  wage-earners  by 
the  Russell  Sage  Foundation  disclosed  that  in  addition  to  using 
up  savings  the  deprivation  of  income  was  met  (i)  by  relief  socie- 
ties, (2)  by  relatives  and  friends,  who  were  undermining  their 
own  health  and  strength  in  order  to  help  others;  (3)  by  employers 
and  trade  unions,  and  (4)  by  borrowing  money,  taking  in  lodgers. 


8o 

sending  the  wife  to  work,  committing  children  to  institutions, 
and  moving  to  cheaper  quarters — all  of  which  tend  to  reduce 
the  standard  of  living  and  to  multiply  sickness.  In  75  per  cent, 
of  the  applications  for  aid  to  the  New  York  Charity  Organization 
Society,  sickness  was  directly  or  indirectly  responsible.  About 
eight-tenths  of  the  relief  expenditure  of  the  New  York  Associa- 
tion for  Improving  the  Condition  of  the  Poor  is  made  necessary 
by  sickness.  In  short,  sickness  was  found  to  be  a  factor  in 
seven  times  as  much  dependency  as  is  industrial  accident.  The 
economic  loss  due  to  the  impaired  vitality  of  wage-earners,  and 
to  that  of  ill-nourisht  and  ill-cared-for  children  when  they  come 
to  working  age,  cannot  at  present  be  accurately  measured,  but 
it  must  be  considerable.  Moreover,  altho  much  of  it  is  prevent- 
able, there  are  no  signs  that  sickness  in  America  is  diminishing. 
On  the  contrary,  deaths  in  middle  life,  due  to  degenerativ  dis- 
eases, have  increast  in  the  United  States  40  per  cent,  during  the 
last  twenty-three  years.  Until  some  means  is  found  to  pre- 
vent illness,  and  to  distribute  its  cost,  sickness  will  continue 
to  produce  destitution,  dependency,  inefficiency,  waste,  and 
death. 

RKSPONSIBIUTY  FOR  SICKNESS. 

The  committee  also  found  that  responsibility  for  sickness 
may  with  justice  be  divided  among  three  parties — the  employer, 
the  workman,  and  the  state. 

While  not  to  the  same  extent  as  for  industrial  accidents,  the 
employer  is  nevertheless  largely  responsible  for  the  sickness 
which  assails  his  workmen,  and  interferes  with  the  stability 
of  his  working  force.  Every  new  man  broken  in,  every  man 
transferred  from  his  regular  work  to  take  the  place  of  a  worker 
who  is  absent,  represents  a  definit  financial  loss,  and  much  of 
this  loss  is  but  the  employer's  chickens  coming  home  to  roost. 
Often  by  conditions  common  to  his  trade,  such  as  monotony  of 
work,  speeding  up,  and  a  work-day  of  unhygienic  length,  and 
also  by  payment  of  wages  inadequate  for  proper  food,  clothing, 
shelter,  and  recreation,  he  undermines  the  vigor  and  resisting 
powers  of  his  workpeople,  so  that  the  omnipresent  bacteria  of 


8i 

disease  find  the  ground  well  prepared.  Not  infrequently,  also, 
improper  heating,  inadequate  dust  removal,  or  the  presence  of 
lead,  arsenic,  mercury,  wood  alcohol,  or  any  other  of  fifty-four 
well-known  industrial  poisons,  cause  illnesses  whose  occupational 
origin  is  even  more  direct  and  unmistakable.  "A  great  many  of 
our  own  industries,"  reports  the  New  York  Factory  Investigating 
Commission,  "are  at  present  carried  on  under  such  abnormal 
conditions  that  they  unduly  increase  the  morbidity  and  mor- 
tality rate  of  the  workers."  The  experience  of  the  Leipsic 
health  insurance  fund  shows  a  variation  of  from  20  to  65  per 
1,000  in  the  sickness  rate  for  different  occupations. 

This  does  not  absolve  the  workman,  however,  from  all  com- 
plicity in  his  own  ill  health,  particularly  if  he  nails  down  the  win- 
dows in  his  home  on  October  ist,  or  in  the  workroom  refuses  to 
use  the  respirators  provided  for  him.  An  amusing  story  is  told 
of  some  workers  in  a  dusty  white  lead  plant  who  would  not  use 
the  shower  baths  until  they  were  forced  to  run  stript  thru  a  wall 
of  water  in  order  to  reach  their  street  clothes.  In  the  selection 
of  food  and  of  living  quarters,  in  personal  care  and  habits,  the 
man  who  must  bear  the  physical  brunt  of  illness  falls  in  many 
cases  far  short  of  utilizing  to  the  full  the  facilities  for  health  which 
are  at  his  hand. 

The  state  also  is  responsible  for  much  of  om-  sickness.  Inade- 
quate supervision  of  the  water  or  milk  supply  may  mean  an  epi- 
demic of  typhoid.  Thus  George  A.  Johnson,  engineer,  estimates 
that  properly  purifying  the  water  of  American  cities  would  pre- 
vent about  45,000  cases  of  typhoid  and  3,000  deaths  annually, 
at  a  saving  of  $22,500,000  in  the  vital  capital  of  the  nation. 
Failure  promptly  to  discover  and  isolate  foci  of  contagious  dis- 
ease, as  in  the  present  threatening  outbreak  of  infantile  paralysis, 
endangers  a  whole  community.  Protection  of  the  people's 
physique  thru  pure  food  laws  is  yet  in  its  infancy.  Unregulated 
housing  conditions  lead  to  the  unsanitary  slums  of  our  large 
cities,  and  backward  methods  of  garbage  and  sewage  removal 
spread  pestilence  in  their  train.  Towards  encouraging  and  ele- 
vating standards  of  industrial  hygiene  the  state  has  done  much, 
but  much  more  remains  to  be  done. 


82 

The  need  of  the  hour  is  for  some  method  of  bringing  persistently- 
home  to  each  of  these  three  parties — the  individual  employer, 
the  individual  workman,  and  the  state — a  due  sense  of  responsi- 
bility for  the  common  burden  of  sickness,  and  of  enlisting  the 
eager  services  of  each  in  a  thoro-going  campain  of  prevention. 

INADEQUACY   OF  EXISTING  HEAI.TH  AGENCIES. 

A  careful  survey,  furthermore,  convinced  our  committee  that 
existing  health  agencies  were  woefully  inadequate  to  meet  the 
demands  upon  them  either  for  cure  or  for  prophylaxis.  Fortu- 
nately the  vast  body  of  medical  service  is  far  above  the  level  indi- 
cated by  a  recent  advertisement  in  the  Los  Angeles  Times,  which 
ran: 

"PERSONAL— ARE  YOU  SICK?     IF  SO,  BE 
made  well  by  Chiropractic  in  exchange 
for  ladies'  or  gentlemen's  clothing.     All 
kinds   of  diseases  successfully    treated. 
Phone  SOUTH  5532." 
Nevertheless  it  remains  regretably  true  that  the  medical  pro- 
fession as  a  whole  is  not  yet  organized  for  the  maximum  of  social 
service. 

The  tremendous  development  of  medical  science,  in  bulk,  in 
variety,  and  in  elaborateness  of  technique,  has  made  possible 
cures  which  a  generation  ago  were  unthought  of.  But  it  has 
also  brought  about  an  era  of  specialization.  It  now  often  takes 
as  many  physicians  to  tend  a  patient  as  it  takes  tailors  to  make 
a  man.  One  family  has  been  known  in  the  course  of  a  year  to 
engage  the  services  of  a  laboratory  worker,  an  X-ray  man,  a 
general  physician,  an  oculist,  a  dentist,  an  orthopedic  surgeon 
and  a  throat  specialist. 

Such  specialized  service  is  expensiv.  It  can  be  secured  by  the 
wealthy,  to  whom  strict  economy  is  not  an  object.  It  can  also 
be  secured,  free  or  at  merely  nominal  cost,  by  the  very  poor, 
in  the  clinics  and  dispensaries  which,  in  spite  of  uncertain  finan- 
cial support,  have  multiplied  seven-fold  in  the  past  decade  and 
a  half.  The  great  bulk  of  the  people,  however,  between  these 
two  extremes,  are  in  the  main  cut  off  from  the  elaborate  resources 


83 

of  modern  medicine.  Some  method  is  needed  of  placing  these  re- 
sources upon  a  sound  financial  basis  and  of  throwing  them  open 
to  the  masses  of  the  people. 

POSSIBILITIES   OF  HEALTH   INSURANCE. 

Insurance  against  sickness  has  been  successfully  tried  out  in 
many  older  countries.  Germany,  Great  Britain,  Austria,  Hun- 
gary, Russia,  and  five  other  European  nations  have  for  years 
been  reaping  the  advantages  of  this  method  of  meeting  their 
sickness  risk. 

Thus,  after  three  years'  experience  with  compulsory  health 
insurance,  the  British  physicians  confess  that  only  since  the  passage 
of  the  national  insurance  act  of  19 ii  have  they  been  able  to 
treat  anemia  among  the  working  class.  In  Great  Britain,  also, 
the  act  has  stimulated  a  powerful  national  crusade  against  tuber- 
culosis. The  first  effect  has  been  to  increase  the  availability  of 
hospital  beds  already  in  existence  but  previously  inaccessible 
to  workingmen;  the  second  has  been  to  increase  the  actual  ac- 
commodations. Within  two  years  after  the  initiation  of  the 
act  in  England  there  were  3,000  beds  in  process  of  construction, 
150  tuberculosis  officers  had  been  appointed,  150  new  tuberculosis 
dispensaries  had  been  opened,  and  nearly  1,000  shelters  for 
out-of-door  sleeping  had  become  available.  During  the  initial 
eighteen  months,  19,400  insured  tuberculous  persons  were  treated 
at  home,  8,800  thru  dispensaries,  and  19,900  in  institutions, 
making  a  total  of  48,000  insured  tuberculous  persons  who  received 
treatment. 

In  Germany,  where  similar  measures  have  been  in  operation 
twenty-five  to  thirty  years,  markt  results  have  been  achieved. 
There  the  health  insurance  law  has  placed  within  reach  of  the 
working  people  "resources  of  healing  never  dreamt  of  before." 
The  invalidity  funds,  also,  which  afford  benefit  in  case  of  pro- 
longed disability,  are  empowered  to  prevent  the  impending  in- 
validity of  an  insured  person  by  requiring  the  member  to  undergo 
treatment.  In  addition  the  funds  may  promote  general  mea- 
sures for  the  prevention  of  invalidity  or  for  the  improvement  of  the 
general  health  conditions  of  the  population  subject  to  insurance. 


84 

Under  the  provisions  of  the  law,  generous  accommodations  have 
been  provided,  so  that,  in  1910,  47,000  insured  persons  were 
cared  for  in  sanatoria  for  an  average  of  seventy-three  days.  In 
addition  to  the  actual  care  of  disease  undertaken  by  the  funds, 
they  have  been  activ  in  a  campain  of  prevention,  in  part  thru 
health  lectures  and  in  part  thru  the  promotion  of  improved  hous- 
ing. Because  of  the  causal  relation  between  housing  and  sick- 
ness, the  invalidity  funds  have  invested  large  sums  in  improved 
housing  schemes. 

Moreover,  while  life  has  recently  lengthened  in  other  European 
countries  at  a  rate  equivalent  to  five,  ten,  or  even  seventeen 
years  a  century,  in  Prussia  it  has  lengthened  in  twenty-three 
years  at  the  rate  of  twenty-five  years  a  centmy  for  men  and 
twenty-nine  years  a  century  for  women.  No  small  proportion 
of  this  increase  must  be  attributed  to  the  impulse  toward  the  dis- 
covery and  application  of  scientific  medicine  given  by  the  health 
insurance  law  of  1883. 

HISTORY  OF  MODKlv  BII.Iv  FOR   HEALTH   INSURANCE. 

In  June,  19 13,  the  committee's  work  led  to  the  calling  of  the 
first  American  Conference  on  Social  Insurance  in  Chicago.  Gov- 
ernors of  the  main  industrial  states  appointed  delegates,  and  the 
discussions  were  participated  in  by  government  and  labor  bureau 
officials,  economists,  employers,  and  commercial  insurance  men. 
During  the  summer  of  19 14  the  committee  issued  a  tentativ 
statement  of  the  essential  lines  which  it  proposed  to  follow  in 
drafting  a  model  health  insurance  bill. 

The  importance  of  having  people  with  medical  training  and 
experience  cooperate  in  perfecting  the  medical  features  of  the 
bill  was  early  recognized,  and  by  November,  19 15,  the  Amer- 
ican Medical  Association  had  offered  its  assistance  and  appointed 
a  cominittee  of  three.  May  I  suggest  that  no  more  valuable 
service  could  be  rendered  to  the  cause  of  health  insurance  by 
the  American  Academy  of  Medicine  at  this  meeting  than  the 
appointment  of  a  similar  committee? 

In  tentativ  form  18,000  copies  of  the  bill  have  been  distributed 
thruout  the  country,  and  during  the  winter  of  19 15-19 16  repeated 


85 

conferences  were  held  for  its  final  shaping  before  introduction  in 
the  state  legislatures.  Meanwhile  words  of  encouragement 
came  from  all  parts  of  the  country.  Almost  simultaneously 
the  measure  was  introduced  in  New  York,  Massachusetts,  and 
New  Jersey,  and  legislativ  hearings  early  in  March  in  the  two 
former  states  lifted  health  insurance  from  the  seclusion  of  aca- 
demic discussion  into  the  realm  of  practical  politics.  The  Massa- 
chusetts campain  has  just  resulted  in  the  creation  of  a  legislativ 
commission,  similar  to  the  social  insurance  commission  appointed 
in  California  in  19 15,  to  study  the  question  and  to  report  at  the 
forthcoming  session,  and  in  at  least  twenty  states  preparations 
are  under  way  for  the  introduction  of  this  legislation  in  191 7. 

PRINCIPAL  PROVISIONS   OP  THE  MODEL  BIIvL. 

The  bill  that  we  have  workt  out,  as  Professor  Seager  has  con- 
cisely stated,  contemplates  compulsory  health  insurance,  on  the 
ground  that  experience  ever3rwhere  has  shown  that  voluntary 
insurance  will  not  reach  the  classes  which  need  it  most.  Those 
who  are  intelligent  and  foresighted  enuf  voluntarily  to  develop 
plans  are  not  those  over  whom  we  need  feel  most  concern.  For 
others  the  system  must  be  made  obligatory  if  it  is  going  to  render 
the  large  social  service  of  which  it  is  capable. 

The  obligation  to  insure  imposed  by  the  bill  is  to  apply  to  all 
manual  workers,  and  also  to  all  other  employes  earning  not  more 
than  $1,200  a  year.  In  addition,  provision  is  made  for  the  volun- 
tary insurance  of  persons  who  desire  to  benefit  by  the  economies 
of  this  great  cooperativ  plan  and  who  are  not  included  among 
those  who  must  insure. 

'''  The  benefits  proposed  are  of  five  types.  First,  there  are  med- 
ical, surgical,  and  nursing  benefits,  medicines  and  surgical  sup- 
plies, beginning  on  the  first  day  of  illness  and  continuing,  if  neces- 
sary, thru  the  twenty-six  weeks  in  any  one  year  during  which 
cash  benefits  are  to  be  paid. 

"*  The  second  chief  benefit  is  the  cash  benefit,  which  the  bill 
proposes  as  two-thirds  of  wages,  beginning  on  the  fourth  day  of 
illness  and  continuing  during  disability  up  to  twenty-six  weeks 
in  any  one  year. 


86 

^  A  third  type  of  benefits  is  hospital  or  sanatorium  care,  where 
this  is  prescribed,  or  desired,  with  the  consent  of  the  physician. 
In  that  case  the  cash  benefit  to  the  dependent  members  of  the 
family  is  to  be  reduced  to  one-third  of  wages. 

,  A  fourth  benefit  is  the  maternity  benefit,  which  is  to  consist 
of  medical  care  for  the  mother,  and,  in  the  case  of  insured  women, 
of  a  cash  benefit,  for  not  more  than  eight  weeks,  on  the  ground 
that  this  is  a  kind  of  disability  from  capacity  to  earn  wages, 
comparable  with  illness,  and  that  the  need  for  support  during 
this  period  for  wage-earning  women  is  as  great  as  in  the  case  of 
ordinary  illness.  Indeed,  this  need  is  especially  great  because 
of  our  legal  situation,  since  in  some  states  we  prohibit  women 
from  gainful  employment  for  a  certain  period  of  time  before  or  after 
child-birth,  and  therefore  deprive  them,  if  they  are  wage-earners, 
of  their  usual  source  of  income. 

!t  Finally,  there  is  provision  for  a  funeral  benefit  of  not  more 
than  $50.  Funeral  benefits,  as  a  matter  of  fact,  are  the  benefits 
most  eagerly  desired  by  our  wage-earners.  The  working  men  and 
women  of  New  York  State  alone,  for  instance,  paid  in  19 15  to 
four  commercial  insurance  companies  more  than  $29,000,000 
for  industrial  insurance,  which  practically  amounted  to  mere 
burial  benefits. 

The  requisite  funds  for  the  proposed  benefits  are  to  be  contrib- 
uted two-fifths  by  the  employer,  two-fifths  by  the  employe, 
and  one-fifth  by  the  state.  In  view  of  what  has  been  said  re- 
garding the  occupational  factors  in  illness,  it  has  been  thought 
that  this  contribution  of  two-fifths  from  the  employer  is  not  ex- 
cessiv.  Moreover,  as  Professor  Seager  has  well  pointed  out, 
it  is  justified  by  the  importance  of  enlisting  the  employer's  in- 
terest in  the  whole  program  and  his  intelligent  cooperation  in 
the  administration  of  the  insurance  fund.  Our  experience  with 
workmen's  compensation  acts  shows  how  much  can  be  accom- 
plisht  when  we  make  it  financially  profitable.  If  we  are  to 
start  a  "Health  First!"  campain  comparable  with  the  "Safety 
First!"  campain  that  is  now  so  well  launcht  we  must  make  health 
a  paying  investment  for  all  in  a  position  to  promote  it. 

It  would  not,  however,  be  just  to  require  the  employer  to  pay 


87 

all  of  the  cost  of  health  insurance,  as  he  now  rightfully  does  of 
accident  compensation.  The  employe's  personal  habits  are 
responsible  for  much  of  his  own  illness.  Thru  financial  interest 
the  workman  himself  must  be  aroused  to  exercise  more  care  for 
his  own  health,  to  discourage  malingering,  and  to  cooperate 
intelligently  in  the  fair  and  economic  administration  of  the  funds. 
Unless  the  worker  contributes  to  the  fund,  it  is  hard  to  see  how 
he  could  be  given  voice  and  vote  in  its  administration. 

It  is  believed  also  that  the  state  should  bear  about  one-fifth 
of  the  financial  burden,  which  is  probably  not  much  more  than 
it  is  already  paying  in  crude  and  uncoordinated  attempts  at 
public  health  work,  in  public  hospitals  and  sanatoriums,  and  in 
charitable  relief  to  the  destitute  victims  of  unprevented  disease. 

The  administration  of  the  plan,  as  proposed  by  the  bill,  is  to 
be  vested  in  local  mutual  insurance  societies,  to  be  supervised 
by  a  social  insurance  commission  for  the  whole  state.  These 
local  insurance  societies  are  to  be  governed  by  representatives 
elected  in  equal  number  by  the  employers  and  employes  con- 
cerned. Employer  and  employes  are  to  select  members  of  a 
large  committee,  the  same  number  from  each  side ;  this  large  com- 
mittee is  to  select  a  smaller  board  of  directors  for  the  insurance 
society.  As  you  will  observ,  this  is  practically  the  German  plan, 
and  our  confidence  that  it  will  operate  well  in  this  country  when 
establisht  is  based  upon  observation  of  its  success  in  Germany.  We 
see  no  reason  why  in  the  administration  of  such  a  system  there 
should  be  anything  but  the  most  cordial  cooperation.  The  em- 
ployer would  have  no  motiv  for  hampering  the  efficiency  of  the 
plan.  On  the  contrary,  we  believe  that  his  advice  and  assistance 
will  aid  it. 

This  is  to  be  the  general  type  of  administrativ  organization. 
To  supplement  it,  provision  is  made  for  the  organization  of  trade 
societies  in  localities  where  there  are  enuf  individual  employes 
in  particular  trades  to  make  that  administrativ  unit  of  sufficient 
size.  Then  there  is  provision  for  voluntary  organizations,  such 
as  we  have  at  present — labor  unions,  establishment  funds,  and 
the  like — provided  that  they  meet  at  all  points  the  requirements 
of  the  law,  comply  with  regulations  of  the  social  insurance  com- 


88 

mission  designed  to  hold  them  up  to  the  standards  which  the 
law  prescribes,  and  that  they  are  financially  sound. 

The  details  of  the  social  insurance  commission,  the  central 
body  to  have  supervision  over  the  whole  system,  are  left  rather 
shady  in  the  provisional  draft  bill,  because  we  think  this  must 
be  adapted  to  special  conditions  in  the  different  states  that  adopt 
the  system.  It  is  proposed,  however,  that  the  commission  shall 
consist  of  three  members ;  that  their  position  shall  be  non-politi- 
cal as  far  as  possible,  and  that  their  tenure  of  office  shall  be 
long  enuf  to  insure  continuity  of  service  and  the  right  type  of 
commissioner. 

OBJECTIONS  TO  MODEL  BILI.. 

<  Objections  to  the  model  health  insurance  bill  have  come  in 
the  main  from  three  groups. 

A  few  employers  have  objected  on  the  ground  that  the  addi- 
tional burden  would  "drive  industry  out  of  the  state."  Care- 
ful calculations  show,  however,  that  the  employer's  contribution 
will  equal  but  a  little  more  than  i  per  cent,  of  pay  roll,  and  so 
slight  an  expense  need  not  jeopardize  any  industry.  Moreover, 
this  is  the  same  argument  which  was  made  a  few  years  ago  against 
workmen's  compensation,  and  we  have  yet  to  learn  of  a  single 
industry  which  has  left  any  state  because  of  the  burden  of  com- 
pensation payments.  In  fact,  under  the  New  York  State  com- 
pensation law,  the  most  liberal  in  the  world,  it  has  been  found 
that  the  total  cost  to  employers  is  actually  less  than  it  was  under 
the  old  liability  system.  Few  would  go  back  to  the  old  system; 
and  on  the  other  hand  many  are  already  in  favor  of  health  in- 
surance. 

Certain  representatives  of  trade  unions  have  entered  protest, 
usually  not  against  the  purposes  or  principle  of  the  measure, 
but  against  the  provision  that  the  workers  contribute  to  the 
insurance  funds.  In  other  words,  they  are  willing  to  receive 
the  benefits,  but  are  unwilling  to  bear  their  share  of  the  expense. 
Needless  to  say,  a  system  supported  solely  by  the  state  and  by 
the  employers  cannot  be  as  liberal  or  as  efficient  as  one  in  which 
the  injured  persons  themselves  meet  a  just  portion  of  the  ex- 
pense and  participate  in  the  management. 


89 

From  a  certain  element  of  physicians,  also,  dissent  has  been 
heard.  These  practitioners,  largely  "lodge  doctors,"  agree 
with  the  principle  of  universal  health  insurance  and,  in  common 
with  the  leaders  of  the  profession,  recognize  it  as  inevitable 
within  the  next  few  years.  Their  opposition  is  directed  at 
minor  administrativ  details  in  which  they  fear  that  their  inter- 
ests may  not  have  been  sufficiently  safeguarded.  As  the 
movement  for  health  insurance  develops  they  will  be  given 
full  opportunity  to  present  their  concrete  suggestions,  and  there 
is  no  doubt  that  as  is  now  the  case  in  Germany  and  in  England, 
the  medical  men  of  the  country  will  soon  stand  as  a  unit  in  sup- 
port of  this  twentieth  centiuy  device  for  cooperation  within 
the  profession. 

CONCI.USION. 

This,  then,  is  the  situation :  For  oiu*  present  waste  and  suffer- 
ing thru  uncheckt  disease  there  is  a  threefold  responsibihty, 
shared  in  by  employer,  employe,  and  the  state.  Each  of  these 
three  has  a  compeUing  interest,  perhaps  only  dimly  glimpsed 
as  yet,  in  the  prevention  of  preventable  disease  and  in  the  prompt 
succor  and  relief  of  that  which  cannot  yet  be  prevented.  For 
the  attainment  of  these  purposes  the  three  interested  parties 
must  be  welded  together  in  a  progressiv,  educational,  health 
movement,  and  such  a  movement  can  be  called  into  being  only 
thru  a  comprehensiv  plan  of  health  insurance  with  its  bturdens 
equitably  distributed. 


UNEMPLOYMENT  INSURANCE. 

By  RuFus  M.  Potts,  Springfield,  111.,  Insurance  Superintendent,  State  of  Illinois. 

The  branches  of  insurance  which  your  association  has  under 
consideration  this  afternoon,  are  now  collectively  termed  "social 
insurance,"  but  were  formerly  called  "workingmen's  insurance." 
The  latter  term,  however,  dropt  out, of  use,  being  inappropriate, 
because  such  insiwance  was  used  by  many  other  classes  than  manual 
workers. 

I  believe  the  name  social  insurance  is  unsuitable  also.  The 
association  of  ideas  causing  its  use  is  rather  far-fetcht,  but  worse, 
it  has,  for  the  general  public  at  least,  an  unfavorable  and  erroneous 
association  with  the  name  of  the  political  party  called  Socialists. 
The  effect  of  this  in  producing  a  hostile  initial  attitude  in  the 
minds  of  most  members  of  other  political  parties,  is  as  bad  as  if  it 
were  called  Republican,  Progressiv,  Democratic,  or  Prohibition 
insurance.  For  these  and  other  reasons,  I  believe  it  highly  de- 
sirable to  have  a  new  collectiv  name  of  these  branches  of  insur- 
ance, and  I  propose  "Welfare  Insurance."  This  name  is  ac- 
curate, for  it  describes  fully  and  correctly  the  aim  of  all  of  the  kinds 
of  insurance  included.  Neither  has  it  any  hurtful  association 
with  the  name  of  any  political  party  or  doctrine.  Welfare  in- 
surance, then,  is  the  use  of  insurance  principles  and  methods  for 
the  purpose  of  supplying  pecuniary  resources  necessary  to  main- 
tain each  citizen  of  the  United  States,  in  a  state  of  well-being, 
thruout  the  various  misfortunes  and  emergencies  of  life  which 
would  otherwise  destroy  his  well-being  and  cause  in  its  place 
destitution  and  suffering. 

I  believe  that  the  substitution  of  the  name  welfare  insurance 
for  social  insurance  would  be  of  immense  service  in  bringing 
about  its  favorable  consideration  by  the  people  in  general  and  its 
ultimate  adoption  which  can  only  be  secured  thru  their  ap- 
proval. 

Turning  to  unemployment  insurance,  that  branch  of  welfare 
insurance  which  is  my  subject,  we  find  that  in  the  earliest  stages 


91 

of  civilization,  there  was  no  unemployment  problem.  Slaves 
did  most  of  the  work  and  their  complaint  was  not  lack  of  work, 
but  too  much  work.  In  such  nations,  however,  as  the  ancient 
Hebrews,  where  there  was  little  slavery,  but  where  sufficient  in- 
dustrial development  had  occurred,  so  that  some  men  could  not 
alone  do  all  their  work,  but  found  it  necessary  to  hire  others,, 
the  two  economic  classes  of  employer  and  employe  came  into 
existence  and  maladjustment  between  the  needs  and  wishes 
of  the  two  classes  inevitably  arose.  On  the  employer's  side,  this 
was  lack  of  sufficient  workers  or  of  competent  workers,  and  often 
occurred.  On  the  employe's  side  the  imperfect  adaptation  was 
lack  of  remunerativ  employment,  which  attracted  attention  nine- 
teen hundred  years  ago,  for  it  was  mentioned  by  our  Saviour  in 
his  parable  about  the  laborers  in  the  vineyard  as  follows: 

And  about  the  eleventh  hour  he  went  out  and  found  others  standing  idle 
and  saith  unto  them:  Why  stand  ye  here  all  the  day  idle?  They  say  unto 
him,  Because  no  man  hath  hired  us.^ 

It  is  an  industrial  phenomenon  entirely  independent  of  race 
or  country.  Over  a  thousand  years  ago,  Wang  Ngan  Shih,  a 
Chinese  statesman,  enunciated  a  set  of  fundamental  principles, 
based  on  the  experience  of  that  nation,  which  he  held  should  be 
observed  by  governments.     One  of  these  was: 

"A  state  should  insure  work  for  workmen,"  which  shows  that 
unemployment  even  at  that  early  time,  had  become  a  problem 
in  China. 2 

In  considering  unemployment  then,  we  are  not  dealing  with  a 
new  problem,  but  the  rapid  changes  in  the  methods  of  industry 
dtu-ing  the  past  150  years,  sometimes  called  the  "industrial  revo- 
lution," have  caused  it  to  attract  more  attention  from  law  makers 
and  students  of  public  affairs  than  formerly.  This  increast 
attention  is  also  partly  due  to  the  steady  growth  of  democracy 
thruout  the  world  and  to  the  invention  and  adoption  of  new  and 
more  humane  and  effectiv  methods  for  dealing  with  misfortune 
and  relieving  or  mitigating  resulting  human  misery. 

Unemployment  is  a  word  which  is  its  own  definition,  for  any- 

1  Matthew,  20:  6-7. 

*  China  Revolutionized,  J.  S.  Thomson,  p.  557. 


92 

one  knowing  the  English  language  understands  that  it  is  the  state 
of  not  being  engaged  in  useful  and  remunerativ  labor.  Unem- 
ployment is  of  two  kinds:  voluntary,  where  the  individual  does 
not  have  the  desire  to  work;  and  involuntary  unemployment, 
where  the  individual  is  willing  to  work  and  able  to  work,  but  can- 
not get  work.  The  first  class  may  be  called  "won't  works," 
the  second  class  "can't  find  works."  What  proportion  of  the 
unemployed  belong  to  the  "won't  works"  and  what  to  the  "can't 
find  works,"  is  not  shown  by  general  statistics.  In  the  winter 
of  19 13-14,  however,  a  special  study  was  made  of  two  thousand 
unemployed  men  in  the  municipal  lodging  houses  of  New  York 
City.  From  this  it  appeared  that  about  35  per  cent,  of  those 
homeless  men  were  unemployable.  Some  of  these  were  phys- 
ically and  mentally  disabled,  others  habitual  loafers,  confirmed 
beggars  or  petty  criminals.  The  remaining  65  per  cent,  were 
willing  and  able  to  work.  The  proportions  of  these  two  classes 
vary  from  time  to  time.  In  good  times,  such  as  prevail  at  pres- 
ent, the  unemployed  will  be  practically  all  "won't  works,"  while 
in  hard  times,  a  great  majority  will  be  "can't  find  works." 

Any  extended  discussion  of  measures  for  dealing  with  voluntary 
unemployment  do  not  come  within  the  scope  of  this  article.  The 
physically  disabled  should  be  relieved  by  charity.  The  much 
more  numerous  class  of  vagrants  and  incorrigible  loafers;  the 
vicious  and  criminal  should  be  firmly  dealt  with  by  being  placed 
in  farm  colonies  or  other  institutions  where  they  can  be  and  will 
be  compelled  to  work,  at  least  sufficiently,  to  produce  the  food 
and  supply  the  other  necessities  of  their  useless  existence. 

Our  attitude  should  be  very  different  toward  those  unfortunate 
workers  who  are  suffering  from  involuntary  unemployment; 
who  are  able  and  willing  to  work  but  cannot  find  work.  Our 
first  inquiry  as  to  them  should  be  to  find,  if  possible,  what  are  the 
causes  of  their  involuntary  unemployment. 

Unemployment  arises  from  the  incapacity  of  industry  to  ab- 
sorb the  whole  supply  of  labor  at  any  given  time.  A  brief  study 
of  the  cause  of  this  incapacity  will  convince  everyone,  that  the 
waves  of  great  prevalence  of  unemployment  occurring  at  inter- 
vals of  several  years  called  "hard  times,"  as  well  as  the  consider- 


93 

able  amount  of  chronic  involuntary  unemployment,  are  in  the 
last  analysis  due  almost  wholly  to  the  imperfect  adjustment  of 
production  to  demand.  The  organization  of  industry  is  still 
crude,  awkward  and  full  of  defects,  so  that  irregularities  con- 
tinually occur  in  the  amount  of  work  ofiFered.  There  is  no  in- 
herent necessity  that  this  should  be  so.  If  production  and  dis- 
tribution were  properly  adjusted,  there  would  always  be  a  de- 
mand sufficient  to  consume  all  the  time,  all  the  products,  that 
all  the  workers  of  the  world  could  produce.  You  will,  I  believe, 
realize  the  truth  of  this  in  a  moment  without  extended  argu- 
ment, if  you  reflect  how  practically  limitless  are  human  wants 
and  desires.  I  do  not  suppose  there  is  any  man  or  woman  in  this 
audience,  much  less  in  the  general  population,  who  is  able  to  ob- 
tain all  the  commodities  that  he  or  she  desires.  Altho  it  is 
easy  to  see  that  every  member  of  this  audience  is  clothed  in  fine 
raiment  and  no  doubt  each  fares  sumptuously,  and  rides  in  auto- 
mobiles every  day,  nevertheless,  I  doubt  not  that  each  of  you 
cherishes  unfulfllled  wishes  for  things  someone  else  could  make, 
and  would  be  glad  to  make,  and  sell  you. 

I  know,  you  know,  everybody  knows,  that  even  in  our  own 
fortimate  land  which  is  not  afflicted  by  war,  or  pestilence,  where 
the  most  fertile  soil  produces  perennially  in  rich  abundance, 
there  are  to-day  thousands,  yes  millions,  who  can  only  get  scanty 
and  unpalatable  food,  who  can  only  secure  the  poorest  and  coarsest 
clothing,  who  in  sickness  must  go  without  physician's  and  nurse's 
care.  There  are  many,  many  more  who  have  a  fair  measure  of 
these  necessaries,  yet  live  barren  lives  without  books,  or  music 
or  opportunity  of  recreation  or  travel  and  innumerable  other 
things  which  make  life  pleasant.  This  infinit  number  of  legitimate 
but  unfulfilled  wishes  and  needs,  proves  that  it  is  only  by  reason 
of  serious  defects  in  our  present  industrial  and  social  organiza- 
tion, that  anyone  willing  to  work  to  supply  these  needs,  is  unem- 
ployed. 

Subsidiary  causes  of  involuntary  unemployment  are  lack  of 
knowledge  of  the  worker  where  work  is;  lack  of  means  whereby 
the  worker  can  transfer  himself  cheaply  and  rapidly  from  one 
job  to  another;  seasonal  occupations;  the  temporary  displace- 


94  I 

ment  of  workers  by  new  machinery;  lack  of  adaptability  to  new 
work  on  account  of  old  age  or  mental  or  physical  weakness;  lack 
of  industrial  training,  either  in  youth  or  adult  life ;  over-specializa- 
tion which  confines  the  chances  of  employment  to  small  subdi- 
visions and  particular  operations  of  industry;  and  irregular  buy- 
ing habits  of  consumers.  All  of  these  causes  of  unemployment 
are  absolutely  beyond  the  control  of  the  individual  worker  and 
can  only  be  regulated  by  coUectiv  action. 

The  effect  of  unemployment  and  the  resulting  lack  of  proper 
food,  etc.,  upon  workers  does  not  require  any  extended  descrip- 
tion or  explanation,  least  of  all  to  physiologists.  The  human 
organism,  unfortunately,  is  not  like  a  steam  engine  in  which  the 
fires  can  be  extinguisht  and  then  allowed  to  stand  cold  without 
expense  until  put  to  work  again.  The  human  mechanism  re- 
quires continuous  supplies  of  fuel  in  the  form  of  food,  as  well 
as  clothing,  and  other  necessaries.  If  it  once  stops  and  grows 
cold,  the  most  expert  physician  in  the  world  cannot  start  it  again. 
Unemployment  inevitably  causes  suffering  and  deterioration, 
and  is  always  followed  by  an  increase  in  pauperism  and  crime, 
and  so  is  a  direct  economic  loss.  In  those  cases  where  the  worker 
has  been  able  to  accumulate  some  money  in  a  savings  bank,  by 
investment  in  a  home,  or  otherwise,  as  long  as  such  resource 
holds  out,  neither  he  nor  his  family  will  endure  physical  suffer- 
ings. But  there  is  a  great  number  who  have  no  such  accumula- 
tions, and  such  as  do  have  them,  must  exhaust  them  sooner  or 
later,  so  that  poverty  and  hunger  are  certain  unless  some  means 
of  prevention  or  relief  can  be  found. 

Before  proceeding  to  the  consideration  of  the  methods  of 
dealing  with  unemployment,  we  should  have  some  reliable 
information  as  to  the  amount  of  unemployment  during  the  whole 
year,  and  at  the  particular  seasons  of  the  year.  When  we  come 
to  examine  this  branch  of  the  subject,  we  find,  however,  that 
there  are  no  such  statistics  covering  the  whole  of  the  United 
States  and  but  little  for  smaller  areas. 

Even  with  all  the  facilities  at  the  command  of  the  United 
States  Bureau  of  Labor  Statistics,  its  Chief  is  obliged  to  say: 


95 


To  the  frequent  question  as  to  the  amount  of  unemployment  in  this  country 
the  reply  must  be  made  that  the  statistics  do  not  make  possible  any  estimate 
of  the  number  of  unemployed  persons  in  the  United  States  at  any  time.^ 

Some  statistics  have  been  accumulated  in  New  York  and 
Massachusetts  as  to  unemployment  among  the  members  of  labor 
unions,  but  they  cover  only  a  part  of  the  working  population 
and  show  such  discrepant  results  that  no  general  inferences  can 
be  drawn  from  them. 

They  have,  however,  some  value  as  being  for  two  typical  in- 
dustrial states  representing  the  best  that  has  so  far  been  obtained 
in  the  line  of  unemployment  statistics  in  the  United  States  cov- 
ering as  much  as  a  whole  state,  so  that  I  present  them  for  what 
they  are  worth. 

It  will  be  observed  that  these  tables  show  a  wide  difference 
between  the  results  in  these  two  adjoining  states;  I  have  not 
seen  any  reasons  given  for  this  and  I  am  unable  to  suggest  any 
myself. 

Number  and  Percentage  of  Members  of  Labor  Unions  Idle  in  the 
State  of  New  York  at  End  of  March  and  September,  1897  to  19 ii. 

Idle  at  the  end  of  March.  Idle  at  the  end  of  September. 


Number     Percentage 

in  all  in  all 

Years.                     unions.  unions. 

1897 43,654  30.6 

1898 38,857  21.0 

1899 31,751  18.3 

1900 44,336  20.0 

1901 42,244  18.5 

1902 36,710  13.6 

1903 41,941  12.  I 

1904 101 ,886  27  .6 

1905 54,916  15. 1 

1906 37,237  9-9 

1907 77,269  19. 1 

1908 138,131  35-7 

1909 74,543  21. 1 

1910 62,851  16. 1 

1911 96,608  20.3 

>  Bulletin  109,  U.  S.  Bureau  of  Labor, 


Percentage 
in  repre- 
sentative 
unions. 


Percentage 
Percentage    in  repre- 
in  all        sentative 
unions.        unions. 


17-3 
17  .6 
27. 1 
19.2 
II. 6 
18.3 
37-5 
23.0 
22  .6 
25.6 
p.  6  (1912). 


Number 

in  all 
unions. 

23,230 
22,485 
9,590 
31,460 
18,617 

18.377 
33,063 
36 , 605 
17,903 
21,573 
42,658 
80,576 
36,968 
63,106 
50,390 


6.3 

9-4 

12  .0 

5-9 
6.3 
12.3 
24.6 
14-5 
12.5 
II  .2 


96 

Number   and   Membership   of   Labor    Organizations   Reporting   and 

Number  of  Members  and  Percentage  of  Membership  Idle  at  End 

OF  Quarters  Specified,  Massachusetts,  1908  to  19 it. 

Idle  at  end  of  quarter. 

Number       Reporting ' k 

Quarter  ending.  unions.         members.       Members.     Percentages. 

Mar.  31,1908 256  66,968  11,987  17.90 

June  30,1908 493  72,815  10,490  14.41 

Sept.  30,1908 651  83,969  8,918  10.62 

Dec.  31,1908 770  102,941  14.345  13-94 

Mar.  3i>  1909 777  105,059  11,997  11.42 

June  30,1909 780  105,944  6,736  6.36 

Sept.  30,1909 797  113,464  5.451  4-8o 

Dec.  31,1909 830  107,689  10,084  9.36 

Mar.  31,1910 837  117,082  8,262  7.06 

June  30,1910 841  121,849  8,518  6.99 

Sept.  30,1910 845  118,781  6,624  5.58 

Dec.  31,1910 862  122,621  12,517  10.21 

Mar.  31,1911 889  122,002  12,738  10.44 

June  30,1911 897  135,202  8,927  6.60 

Sept.  30,1911 975  133,540  7,527  564 

Dec.  30,1911 905  125,484  12,167  970 

An  attempt  has  been  made  to  get  some  idea  of  the  amount 
of  unemployment  by  another  method.  Taking  a  selected  list 
of  manufacturers  for  the  year  1909  according  to  the  reports  of 
the  Census  Bureau,  a  table  was  constructed  which  gives  what 
percentages  the  emplo)anent  for  the  month  of  least  employment 
in  them  all,  was  of  the  amount  of  employment  in  the  month  of 
greatest  employment.  This  list  contains  261  industries  and 
shows  that  on  an  average  the  amount  of  employment  in  the 
month  of  least  employment  was  88.6  per  cent,  of  the  amount 
of  employment  in  the  month  of  greatest  employment;  that  is — 
1 1 . 4  per  cent,  of  unemployment  in  the  worst  month.  The  aver- 
age number  employed  diu'ing  the  year  in  the  manufacturies 
concerned  in  the  above  list  was  6,615,046,  so  that  in  them  the 
total  unemployed  in  the  worst  month  was  approximately  the 
immense  number  of  754,000.^ 

A  witness  at  a  hearing  before  a  Congressional  Committee,  who 
testified  that  she  had  been  engaged  in  the  study  of  the  question 
of  unemployment  for  eight  years  in  Europe  and  the  United  States, 

*  Testimony  of  Miss  Juliet  Stuart  Poyntz,  pp.  52,  60  and  61,  Report  of  Hearings 
before  Committee  of  Labor,  House  of  Representatives,  64tb  Congress,  1st  Session,  on  H.  J. 
Res.  159. 


97 

says,  in  relation  to  the  relativ  amount  of  unemployment  in  the 
United  States  compared  with  other  countries : 

I  would  like  also  to  say  that  the  problem  in  America  is  more  serious  than 
in  Europe.  Not  more  than  lo  or  15  years  ago  it  was  the  general  belief  that 
there  was  no  problem  of  unemployment  in  America  such  as  there  was  in 
Europe.  As  a  matter  of  fact,  it  is  a  much  greater  problem  here  than  in 
Europe.  The  percentages  of  trade-union  unemployment  in  New  York  and 
Massachusetts  indicate  that  American  unemployment  rises  to  heights  that 
are  unknown  in  Europe;  that  if  unemployment  is  an  evil  in  Europe  it  is  a 
much  vaster  and  more  serious  evil  in  America.  It  might  be  pointed  out  that 
speculation  makes  industrial  changes  much  more  rapid  in  this  country  and 
that  transitions  in  our  industries  result  in  greater  fluctuations.  There  are 
great  fluctuations  in  all  the  industries  affected  by  style,  as,  for  instance,  in  the 
garment  and  boot  and  shoe  industries,  which  are  developt  in  this  country 
to  a  much  greater  extent  than  in  Europe.  Unemployment  is  peculiarly  our 
problem.  If  all  the  countries  of  Europe  have  been  interested  in  this  problem, 
America  should  be  certainly.  During  the  great  crises  which  have  swept  over 
the  countries  of  Europe  within  the  last  two  decades  the  trade-union  un- 
employment percentages  have  rarely  risen  above  10  per  cent.,  whereas  in  the 
United  States  the  general  percentage  of  unemployment  has  risen  above  20 
and  even  30  per  cent.^ 

According  to  the  census  of  1900,  the  number  of  persons  un- 
employed at  some  time  during  that  year  was  6,468,364,  of  whom 
3>i77>735  lost  from  one  to  three  months,  and  2,554,923  from  4 
to  6  months. 2 

According  to  the  census  of  19 10  there  were  in  round  numbers, 
6,000,000  persons  who  were  unemployed  at  some  time  during 
the  year,  but  concerning  these  figures,  the  Commissioner  of 
the  Btu-eau  of  Labor  Statistics  says : 

In  regard  to  the  amount  of  unemployment  we  know  almost  nothing.  Those 
figures  by  the  census  are  estimated,  at  best.  They  are  taken  in  the  month 
of  April,  and  in  that  month  the  various  people  interviewed  by  the  various 
agents  of  the  Census  Bureau  are  required  to  estimate  if  they  were  out  of 
employment  during  the  past  year,  and  if  so,  how  long.  Now,  I  submit  that 
that  is  extremely  precarious  data  upon  which  to  build  any  very  elaborate 
superstructure,  for  those  estimates  are  extremely  inaccurate  for  they  in- 
clude guesses  at  all  unemployment  from  all  causes — voluntary  idleness  for 
the  purpose  of  taking  a  vacation,  idleness  due  to  sickness  or  other  disability, 

1  Testimony  of  Miss  Juliet  Stuart  Poyntz,  pp.  60  and  61,  Report  of  Hearings  before 
Committee  of  Labor,  House  of  Representatives,  64th  Congress,  1st  Session,  on  H.  J.  Res.  159. 

*  Testimony,  Dr.  B.  A.  Sekely,  p.  15,  Rep.  of  Hearings  before  Committee  of  Labor, 
House  of  Representatives,  64th  Congress,  1st  Session,  on  H.  R.  5783. 


98 

idleness  due  to  strikes  or  lockouts — in  short,  the  census  figures  include  every- 
thing that  was  in  your  mind,  I  think,  when  you  put  your  question,  Mr. 
Congressman. 

Nobody  knows  whether  6,000,000  people  were  out  of  employment  part 
of  the  year  19 10,  or  whether  10,000,000  people  were  out  of  employment 
part  of  the  year,  and  nobody  knows  anything  about  the  industries  and 
occupations  affected,  and  nobody  knows  anything  about  the  periods  of  idle- 
less  of  these  men  and  the  causes  of  idleness.^ 

More  valuable  information  can  be  obtained  from  more  limited 
investigations  of  unemployment.  In  the  early  part  of  19 15, 
the  United  States  Bureau  of  Labor  Statistics  made  a  complete 
census  of  104  representativ  city  blocks  located  in  various  sec- 
tions of  New  York  City,  the  less  populated  as  well  as  the  more 
congested  section,  and  in  addition  of  families  living  in  3703  indi- 
vidual tenement  houses  and  residences  also  widely  distributed. 
This  showed  that  16.2  per  cent,  of  the  wage  earners  in  these  fami- 
lies were  unemployed,  and  on  this  basis  it  was  estimated  that 
the  total  number  of  unemployed  in  New  York  at  that  time  was 
approximately  398,000.  In  January,  19 15,  the  Metropolitan 
Life  Insurance  Company  made  a  census  of  all  the  families  which 
held  industrial  policies  in  that  Company  in  greater  New  York 
thru  the  agents  who  make  the  weekly  collections.  This  showed 
that  18  per  cent,  of  the  wage  earners  in  the  families  canvast 
(37,062)  were  unemployed.  The  same  company  also  made  a 
similar  canvas  of  its  policy  holders  in  northeastern  New  Jersey 
adjacent  to  New  York  City,  including  Bayonne,  Bloomfield, 
Newark,  Hoboken,  Irvington,  Jersey  City,  Orange  and  Union 
Hill.  In  these  cities  it  was  found  that  14.8  per  cent,  of  the  wage 
earners  were  unemployed.  It  is,  of  cotirse,  certain  that  the  con- 
ditions at  present  are  quite  different  from  those  existing  at  that 
time.  About  aU  that  statistics  establish  is  that  at  certain  times 
there  are,  in  the  United  States,  immense  numbers  of  unemployed 
workers,  sometimes  running  up  into  millions.  This  much  is 
absolutely  certain  and  should  be  sufficient  to  convince  us  that 
unemployment  causes  immense  undeserved  suffering  and  also 
to  impel  us  to  earnestly  seek  remedies.     The  best  way  to  deal 

1  Testimony,  Mr.  Royal  Meeker,  p.  29,  Report  of  Hearings  before  Committee  of  Labor, 
House  of  Representatives,  64th  Congress,  1st  Session,  on  H.  R.  5783. 


99 

with  unemployment  like  disease  is  by  prevention.  It  is  a  hun- 
dred times  better  to  prevent  workers  being  thrown  out  of  work 
when  possible,  or  to  at  once  furnish  them  another  position,  than 
merely  attempt  to  relieve  their  destitution  resulting  from  unem- 
ployment. 

Since,  as  we  have  seen,  the  fundamental  causes  of  unemploy- 
ment are  defects  in  our  industrial  and  economic  organization 
and  the  irregularities  of  labor  demand  resulting  therefrom,  the 
primary  thing  is  to  reorganize  our  industrial  and  economic  sys- 
tems so  that  these  irregularities  will  not  occur.  This  is  the  great 
question  of  the  present  age,  but  unfortunately  no  agreement  has 
been  reacht  about  what  should  be  done,  or  how  it  should  be  be- 
gun, altho  numerous  political  parties  have  written  platform 
planks  about  it  and  innumerable  politicians,  reformers,  states- 
men, filanthropists,  religious  teachers  and  filosofers,  have 
given  it  their  earnest  attention.  I  will,  of  course,  not  at- 
tempt to  solve  this  prohlema  problematorum  (problem  of  prob- 
lem) for  you  this  afternoon,  but  will  leave  it  for  those  earnest 
souls  bravely  struggling  with  it.  I  wdll  only  venture  to  suggest 
that  much  has  been  done  to  regularize  labor  demand,  by  the  volun- 
tary efforts  of  employers  to  so  carry  on  their  factories  or  other 
industrial  enterprises,  that  their  working  people  will  be  furnisht 
employment  thruout  the  year.  In  those  industries  where  the 
irregularities  arise  from  the  seasonal  causes,  as  in  agriculture, 
construction  work,  building  trades,  etc.,  something  can  be  done 
by  arranging  industries  so  that  when  one  stops  another  will  take 
its  place,  and  furnish  employment  to  the  workers.  In  the  build- 
ing industries,  for  instance,  it  ought  to  be  feasible  to  employ 
the  workers  during  the  winter  season  in  sawing  lumber,  making 
structural  iron  work,  brick  under  cover  and  other  building  ma- 
terial to  be  used  by  the  same  workmen  in  erecting  buildings 
the  coming  summer.  The  problem  of  the  agricultural  laborer 
is  of  course  more  difficult,  but  if  American  agriculture  was  carried 
on  as  it  should  be,  so  that  the  products  of  the  soil  were  manufac- 
tured on  each  farm  into  eggs,  meat,  canned  goods,  dairy  and  other 
finisht  food  products,  work  could  be  found  for  most  of  the  work- 
ers thruout  the  whole  of  the  year,  and  at  the  same  time  the  re- 


lOO 

turns  to  the  farmer  would  be  increast,  and  impoverishment  of 
the  land  by  shipping  away  the  grain  and  forage  raised  thereon 
prevented.  These  are  merely  random  suggestions.  It  would  re- 
quire many  years  of  careful  study  and  experimentation  to  work 
out  a  complete  system  but  I  beUeve  it  can  be  done  and,  in  con- 
nection with  agricultural  co-operation,  would  do  more  for  our 
farmers,  and  incidentally  for  all  classes,  than  any  other  one  thing 
conceivable. 

One  of  the  indispensable  prerequisites  to  such  industrial  regu- 
larization  is  the  improvement  and  cheapening  of  all  branches 
of  our  transportation  system.  This  will  aid  both  in  the  trans- 
portation of  workers  from  place  to  place,  and  by  the  continuous, 
rapid  and  cheap  transportation  of  the  products  of  farming  and 
other  industries  in  small  parcels  direct  to  consumers,  instead  of 
irregularly  by  carloads  and  by  trainloads,  as  at  the  present  time, 
to  one  middleman  after  another. 

Another,  and  probably  the  most  important,  means  of  prevent- 
ing unemployment  is  the  organization  of  a  complete  network 
of  efficient  free  labor  agencies  covering  the  whole  United  States 
with  complete  records  of  all  calls  for  workers  everywhere,  so  that 
the  willing  worker  can  readily  find  the  places  where  his  services 
are  in  demand.  There  should  also  be  some  provision,  by  which 
a  laborer  traveling  to  find  work  could  do  so  at  very  cheap  rail- 
road fares,  and  find  very  low-priced  and  wholesome  board  and 
lodging  while  doing  so.  Such  a  system  of  labor  exchanges  has 
been  developt  in  Germany  where  it  has  been  of  immense  service. 
In  the  management  of  the  German  bureaus  are  included  repre- 
sentatives of  all  classes  concerned,  and  combined  with  them  are 
frequently  shelter,  lunch  rooms,  waiting  rooms,  reading  rooms, 
etc. 

There  is  spent  in  the  United  States,  at  the  present  time,  in 
support  of  various  labor  agencies,  exchanges,  etc.,  public  and 
private,  an  amount  of  money  sufficient  to  support  a  nation-wide 
and  efficient  system,  if  it  was  properly  organized  under  one  man- 
agement with  full  correlation  by  immediate  telefonic  or  tele- 
grafic  exchange  of  information  between  all  parts  of  the  United 
States.     I  believe  that  this  can  only  be  efifectivly   done   by  the 


lOI 

national  government.  The  labor  demand,  like  commercial  de- 
mand, is  no  respector  of  state  boundaries.  In  order  to  find  work, 
laborers  must  pass  freely  from  state  to  state  and  this  they  can 
only  do  when  they  have  the  information  covering  all  of  the  states 
available  at  any  labor  exchange  where  they  may  happen  to  be, 
and  while  of  course  it  is  theoretically  possible  to  exchange  informa- 
tion between  state  employment  agencies,  practically,  such  a  sys- 
tem could  not  accomplish  the  purpose  with  any  approach  to  the 
efiiciency  of  a  national  system. 

Another  method  of  lessening  unemployment  is  the  carrying 
on  of  such  work  as  building  canals,  highways,  harbor  improve- 
ment, irrigation  and  drainage  works,  reforestation  and  many 
other  kinds  of  public  work  dining  slack  times.  This,  of  course, 
would  involv  planning  ahead  and  thoro  organization  of  all  of 
these  governmental  activities,  but  if  sufficient  political  and  social 
foresight  were  used,  great  relief  would  be  afforded  in  panics  when 
millions  of  workers  are  suddenly  thrown  out  of  employment. 

Interesting  suggestions  concerning  relief  by  public  works, 
etc.,  are  given  by  the  recommendations  made  by  the  Unemploy- 
ment Advisory  Board  of  New  South  Wales,  calling  for  the  crea- 
tion of: 

1.  A  national  intelligence  department  for  men  and  women. 

2.  Labor  depots,  where  the  unemployed  can  be  temporarily  sheltered  and 
employed. 

3.  Industrial  farm  settlements — an  expansion  of  the  labor  depot,  where 
the  men  are  given  work  and  technical  instruction. 

4.  Assisted  settlement  blocks,  where  the  men  who  graduate  from  the  in- 
dustrial farm  settlements  are  given  farms  of  their  own. 

5.  Compulsory  labor  farms  for  the  vagrants. 

6.  Subsidies  to  mineral  prospectors,  advances  to  settlers,  allotment  of 
land  to  societies  formed  to  settle  cooperativly,  treasury  advances  for  the 
establishment  of  cooperativ  industries  in  the  assisted  settlement  blocks,  and 
instructions  in  agriculture  in  the  primary  schools. 

Another  method  of  dealing  with  unemployment  is  so-called 
"relief  work."  This  is  something  done  solely  for  the  purpose  of 
furnishing  support  to  the  unemployed.  It  has  not  been  very 
successful  and  is  usually  considered  as  a  disguised  form  of  charity. 


I02 

But  in  some  of  the  industrial  crises  such  as  that  of  1907,  some- 
thing of  the  kind  appeared  to  be  necessary.  ^ 

For  deahng  with  such  unemployment  as  remains  after  a  faith- 
ful application  of  such  preventiv  measures  as  I  have  just  de- 
scribed, instead  of  charity  the  most  effectiv  way  is  by  insurance 
methods.  I  suppose  there  is  not  a  person  here  who  does  not 
have  some  understanding  of  the  theory  of  insurance  so  I  will 
only  need  to  say  that  insurance  in  general  is  a  legitimate  and  well 
tested  business  method  which  by  collecting  contributions  from 
each  one  of  a  large  number  of  individuals  liable  to  suffer  loss 
from  uncertain  occurrences  creates  a  fund,  out  of  which  the  losses 
to  such  of  those  individuals  to  whom  the  contingency  occurs 
will  be  paid,  and  in  this  way  distributes  thruout  the  whole  num- 
ber insured  the  burden  to  the  few  unfortunates  actually  suffer- 
ing loss. 

The  late  Chief  Justice  Ricks,  of  the  Supreme  Court  of  Illinois, 
in  the  course  of  a  decision  involving  the  question  of  the  interest 
of  the  public  in  it,  gave  the  following  eloquent  characterization 
of  the  business  of  insurance  which  I  cannot  improve  on: 

The  business  of  insurance  is  the  outgrowth  of  time  and  the  demands  and 
necessities  of  the  public.  It  extends  into  and  covers  almost  every  branch  of 
business  and  all  the  relations  of  life,  and  is  applied  to  all  the  hazards  of  busi- 
ness in  life  where  a  basis  of  risk  and  compensation  can  be  estimated.  In  all 
the  stages  of  life,  from  the  cradle  to  the  grave,  it  asserts  an  interest  and 
offers  succor  and  aid.  In  the  business  enterprises,  whether  by  land  or  sea; 
in  the  possessions  of  men,  from  a  pane  of  glass  to  the  mansion  or  the  factory; 
in  his  undertakings  involving  every  chance,  misfortune,  moral  turpitude  or 
the  act  of  God,  it  demands  admission  and  promises  indemnity,  reward  or  gain. 
It  poses  as  the  faithful  and  zealous  trustee  of  his  earnings  and  savings,  and 
promises  to  the  widow  and  orphan  a  guaranty  against  misery  and  want. 
It  intercedes  between  principal  and  ag^nt,  master  and  servant,  contractor 
and  owner,  and  insures  against  loss  from  almost  any  and  every'  cause.  It 
is  a  public  necessity  that  deals  in  its  own  credit  for  a  cash  consideration  from 
the  assured,  and  is  stamped  with  public  interest,  and  must  yield  obedience 
to  necessary  and  proper  regulations  by  the  State  in  the  exercise  of  its  police 
power.2 

^  A  very  instructiv  account  of  the  practical  and  effectiv  methods  in  use  in  Switzerland 
for  dealing  with  the  unemployment  problem  is  contained  in  an  article  by  Edith  Sellers 
in  Nineteenth  Century  64:  763  reprinted  in  volume  on  Unemployment  in  "Debaters  Hand- 
book Series." 

»  North  American  Ins.  Co.  vs.  Yates,  214  III.  272  (275). 


I03 

Altho,  there  are,  of  course,  difficulties,  there  is  no  inherent 
impossibility  in  making  provision  against  the  effects  of  unem- 
ployment by  insurance  methods.  This  is  proven  by  the  fact 
that  a  nation-wide  unemployment  insurance  system  is  now  in 
successful  operation  in  England,  with  local  unemployment  in- 
surance systems  in  various  other  European  countries,  while  even 
in  the  United  States  this  function  is  to  some  extent  fulfilled  by 
some  of  the  labor  unions. 

Unemployment  insurance  may  be  carried  on  in  two  ways: 
the  voluntary  and  the  compulsory.  The  voluntary  form  is 
carried  on  by  associations  or  organizations  of  workers  in  a  par- 
ticular industry  or  trade,  and  usually  is  a  part  of  the  activities 
of  an  ordinary  trade  union  which  collects  benefit  funds  to  be 
paid  to  its  members  when  out  of  employment.  In  some  places 
in  Europe  these  voluntary  associations  are  subsidized  or  given 
aid  by  the  state,  the  city  or  other  political  division.  This  subsidy 
is  usually  in  the  form  of  a  certain  percentage  thereof  added  to 
the  contribution  made  by  the  organization.  This  is  usually 
known  as  the  Ghent  system  because  it  was  first  used  in  the  Belgian 
city  of  that  name.  The  contribution  by  Ghent  was  60  per  cent, 
of  the  amount  contributed  by  the  Union.  The  city  also  main- 
tains a  municipal  labor  exchange  in  the  management  of  which 
the  unions  and  the  employers  have  equal  representation.  Any 
workman  desiring  to  obtain  the  unemployment  benefit  must 
report  at  the  Labor  Exchange  that  he  is  unemployed  and  it  en- 
deavors to  find  work  for  him.  Not  until  the  bureau  has  failed 
to  obtain  work  for  him  can  the  workman  obtain  money  from  the 
unemployment  insurance  fund.  This  plan  or  some  modifica- 
tion has  been  adopted  in  many  of  the  cities  of  Belgium,  twenty- 
five  cities  in  Holland,  twenty  in  France,  ten  in  Germany,  three 
in  Italy  and  two  in  Switzerland. 

In  favor  of  the  Ghent  or  similar  system,  are  the  ease  with 
which  it  can  be  administered  thru  existing  agencies  of  labor 
unions,  and  the  fact  that  all  claims  go  thru  the  hands  of  union 
officers  who  are  familiar  with  all  the  features  of  the  labor  market, 
in  the  trade  in  which  the  applicant  works,  which  diminishes 
opportunities  of  fraud,  and  that  it  results  in  encouragement  of 


I04 

individual  thrift  and  initiativ,  because  it  only  helps  those  who 
are  willing  to  help  themselves. 

On  the  other  hand,  it  is  urged  by  some  that  it  is  wholly  improper 
for  the  government  to  subsidize  labor  unions  as  in  the  Ghent 
plan,  because,  according  to  their  own  statement,  they  are  fighting 
organizations,  so  that  subsidies  out  of  public  fund  would  amount 
to  taxing  employers  to  pay  the  expense  of  men  who  are  opposing 
them,  which  would  be  absolutely  unjust.  Also  that  the  cost  of 
a  system  of  unemployment  insurance  is  very  heavy,  and  if  carried 
on  in  such  a  manner,  as  not  to  amount  to  subsidizing  idlers  and 
shirkers,  would  require  practices  and  inquisitorial  methods 
which  would  create  immense  dissatisfaction,  and  probably  be  im- 
possible under  our  form  of  government  where  the  recipients  are 
voters  and  have  political  power,  which  would  be  ceaselessly  ex- 
erted in  their  own  favor. 

Extreme  individualists  take  exception  to  the  compulsory 
features  which  are  necessary  to  make  a  success  of  any  branch 
of  welfare  insurance,  but  above  all,  are  necessary  in  unemploy- 
ment insurance.  It  is  absolutely  useless  to  expect  that  any  form 
of  unemployment  insurance  will  be  taken  advantage  of  or  bene- 
fit a  large  part  of  the  classes  most  needing  it,  unless  it  is  made 
compulsory  in  character. 

Dr.  S.  S.  Huebner,  Professor  of  Insurance  and  Commerce  in 
the  University  of  Pennsylvania,  and  one  of  the  leading  authori- 
ties on  insiu-ance  in  the  United  States  at  the  present  time,  in  a 
recent  address  states  that  insurance  protection  for  wage  earners 
cannot  be  left  to  voluntary  action  either  by  commercial  companies 
or  by  the  government. 

The  present  voluntary  state  life  insurance  plans  of  Massa- 
chusetts and  Wisconsin,  altho  sound  in  principle  and  safe  finan- 
cially and  carried  on  at  cost,  have  made  practically  no  headway. 
The  reasons  for  compulsory  welfare  insurance  are  the  same  as 
those  for  compulsory  education,  compulsory  sanitary  measures, 
compulsory  food  inspection  and  compulsory  fire  precautions, 
and  are  no  more  an  unwarranted  interference  with  the  liberty 
of  a  citizen  than  are  these  and  other  compulsions  to  which  every 


I05 

good  citizen  willingly  submits  because  they  are  for  the  benefit 
of  the  whole  community,  including  himself. 

As  the  density  of  population  and  complexity  of  civilization 
increases,  certain  limitations  of  liberty  of  action  become  abso- 
lutely necessary  under  even  the  freest  and  most  democratic 
form  of  government  that  can.  be  devised.  Under  even  the  most 
attractiv  and  secure  plan  of  voluntary  unemployment  insurance, 
and  also  of  other  branches  of  welfare  insurance,  that  could  be 
devised,  there  would  be  a  large  proportion  of  thoughtless  spend- 
thrifts who  would  fail  to  take  advantage  of  it  to  make  provision 
for  themselves,  or  their  families.  There  should  be  no  reluctance 
for  the  state  to  apply  compulsion  to  those  so  wanting  in  foresight 
and  sense  of  parental  responsibility  as  not  to  make  provision  for 
themselves  and  families,  and  such  a  course  would  not,  I  believe, 
offend  the  strong  individualistic  characteristics  of  the  people 
of  the  United  States  when  once  the  true  purpose  and  immense 
advantages  of  welfare  insurance  are  understood  by  them. 

Against  these  and  possibly  other  disadvantages  of  unemploy- 
ment insurance  there  are  many  benefits  which,  I  believe,  under  a 
properly  planned  and  safeguarded  system,  far  outweigh  the  dis- 
advantages. The  first  and  greatest  of  these  is,  that  it  prevents 
undeserved  suffering  and  destitution.  There  is  nothing  which 
should  more  strongly  engage  our  sympathies  than  the  spectacle 
of  a  man  v/ho  is  able  and  honestly  willing  to  work,  to  get  the  means 
to  support  himself  and  his  family,  but  who  is  not  able  to  find  such 
work.  There  is  no  situation  which  causes  more  undeserved, 
helpless  suffering.  A  system  of  unemployment  insurance,  even 
tho  accompanied  by  difficulties  which  can  prevent  or  even  measur- 
ably mitigate  this  misery,  is  worthy  of  careful  trial. 

Another  benefit  is  that  unemployment  insurance  by  furnish- 
ing support,  when  none  is  otherwise  available,  will  preserv  the 
physical  health  and  the  moral  character  of  the  worker.  Good 
physical  health  and  efficiency  can  only  be  maintained  by  a  regu- 
lar and  adequate  supply  of  food,  clothing  and  proper  shelter. 
Men  and  their  families  must  have  something  to  eat  every  day; 
they  must  have  clothes  to  wear;  they  must  have  shelter  and 
warmth,   and  if  unable  to  gain  these  thru  their  own  exertion, 


io6 

some  will  be  driven  to  crime;  others  will  become  the  unwilling 
recipients  of  charity.  Charity  in  the  proper  cases,  and  occa- 
sionally, is  perhaps  a  blessing  both  to  the  giver  and  to  the  re- 
ceiver, but  if  long  continued,  as  it  would  have  to  be  to  support 
all  the  unemployed  under  modern  industrial  conditions,  would 
become  an  insupportable  burden  to  givers,  and  as  I  have  already 
maintained,  a  source  of  degradation  and  pauperization  to  the 
recipient.  Human  nature  being  what  it  is,  it  is  unfortunately 
true  that  there  is  a  certain  proportion  of  men  and  women,  who, 
when  they  find  that  charitable  relief  will  be  always  forthcoming 
and  become  accustomed  to  receive  the  same,  entirely  lose  the 
motiv  to  work  and  practically  cease  to  work,  depending  on  pub- 
lic or  private  charity. 

This  discreditable  side  of  human  nature  long  ago  attracted 
the  attention  of  wise  men.     The  author  of  the  book  of  Bcclesiastes 
wrote : 
,A11  the  labor  of  a  man  is  for  his  mouth. ^ 

And  in  Proverbs  it  is  said: 

He  that  laboreth,  laboreth  for  himself;  for  his  mouth  craveth  it  of  him.^ 

The  hunger  motiv  is  the  only  one  that  will  drive  a  great  many 
men  to  work,  and  if  this  is  eliminated  by  undiscriminating  charity, 
such  men  will  cease  to  work  at  all,  and  become  able-bodied  un- 
employables.  Fortunately,  as  civilization  and  education  advance, 
a  constantly  increasing  proportion  of  mankind  become  amenable 
to  other  and  higher  motivs  than  hunger,  but  there  is  still,  and 
will  be  for  a  long  time,  those  who  will,  whenever  possible,  gain 
a  living  by  begging  or  stealing,  instead  of  working,  even  when 
abundant  work  is  offered.  For  this  class  our  scorn  and  contempt 
can  hardly  be  too  great,  and  all  social  plans  should  take  into  ac- 
count this  class  and  include  measures  which  will  compel  them 
to  work  to  support  their  useless  existence  instead  of  allowing  them 
to  longer  beg  or  steal,  much  less  furnish  them  with  a  pension 
thru  unemployment  or  other  welfare  insurance  paid  for  by  forced 
contributions  from  the  labor  of  willing  workers. 

The  effect  of  unemployment  insurance  money  received  by  the 

1  Ecclesiastes,  6:7. 
*  Proverbs,  16:26. 


I07 

worker  is  entirely  different  from  charitable  relief.  Because  he 
has  contributed  directly  or  indirectly  to  create  the  fund  from 
which  he  is  paid,  there  is  no  loss  of  self-respect. 

Another  benefit  of  unemployment  insurance  is  that  it  will 
mitigate  industrial  crises  by  maintaining  the  consuming  power 
of  the  worker.  May  I  be  permitted  to  say  in  passing,  that  I 
believe  that  the  Federal  reserv  currency  plan  now  in  force  has 
already  proven  and  will  prove  in  the  future  to  be  an  exceedingly 
important  factor  in  preventing  or  at  least  diminishing  commer- 
cial crises,  commonly  called  "hard  times."  Owing  to  their  im- 
mensely greater  numbers,  the  working  classes  consume  by  far  the 
greater  part  of  the  products  of  all  the  industries,  and  when  this 
consuming  capacity  is  diminisht  by  the  unemployment  of  any 
considerable  part  of  the  laboring  classes,  by  an  industrial  crisis, 
such  crisis  is  thereby  aggravated.  If  only  purchasing  power  for 
the  necessaries  of  life,  such  as  food  and  fuel,  were  maintained,  it 
would  go  a  long  way  to  lessen  all  industrial  crises,  altho,  of 
course,  we  all  recognize  that  there  are  many  other  contributory 
factors  which  must  be  eliminated  before  their  recurrence  can 
be  completely  prevented. 

Unemployment  insurance  would  also  operate  as  a  direct  pre- 
ventiv  of  unemployment,  because  it  would  be  a  direct  financial 
inducement  to  the  employer  to  furnish  regular  work.  In  the 
English  unemployment  insurance  system  there  is  provision  made 
for  a  markt  reduction  of  the  amount  of  contribution  required 
from  the  employer  if  he  furnishes  regular  employment  to  his  work- 
men thruout  the  year  and  this  reward  should  be  a  part  of  every 
unemployment  insurance  system.  The  preventiv  effect  of  un- 
employment insurance  will  be  comparable  to  that  in  favor  of 
accident  prevention,  caused  by  workmen's  compensation  insur- 
ance. 

When  we  come  to  consider  whether  we  should  choose  the  volun- 
tary form,  or  the  compulsory  form,  of  unemployment  insurance 
in  the  United  States,  we  find  that  practically  nothing  has  been 
done  in  unemployment  insurance  by  voluntary  methods,  ex- 
cepting thru  the  labor  unions.  This  is  a  very  important  and 
beneficial  branch  of  their  work,  but  it,  of  course,  is  impossible 


io8 

for  them  to  aid  those  outside  their  membership  and  this  member- 
ship is  only  a  small  per  cent,  of  all  workers.  So  far  as  I  know 
there  is  no  hope  in  any  quarter  that,  outside  of  labor  unions, 
unemployment  insurance  would  or  could  be  made  successful 
on  the  voluntary  plan.  The  only  alternativ  is  compulsory  un- 
employment insurance.  If  this  is  adopted,  it  must  be  carried 
on  by  the  state  or  United  States,  for  two  reasons.  First,  in  order 
to  avoid  the  excessiv  and  unreasonable  expense  of  all  insurance 
by  commercial  methods,  and  in  the  second  place,  because  the  only 
hope  of  making  unemployment  insurance  a  success  is,  as  hereto- 
fore explained,  by  having  it  carried  on  as  the  integral  part  of  a 
nation-wide  system  of  labor  exchanges  or  agencies.^ 

As  the  result  of  investigation  into  the  subject  of  fire  insurance 
which  I  began  in  19 14,  I  have  arrived  at  the  conclusion  as  stated 
in  my  report  on  that  subject,  that  on  account  of  the  excessiv 
expense  incident  to  the  present  method  of  conducting  the  fire 
instuance  business,  and  particularly  owing  to  the  existence  of 
a  nation-wide  fire  insurance  combine,  or  trust,  of  the  most  op- 
pressiv  kind,  which  controls  practically  all  of  the  fire  insurance 
business  of  the  United  States  and  enforces  exorbitant  rates  every- 
where, the  fire  insurance  business  should  be  conducted  by  the 
different  states  or  by  the  United  States.  The  fire  insurance 
combine  is  able  to  do  this,  because  under  modern  commercial 
and  industrial  conditions  where  business  is  largely  done  on  credit, 
fire  insurance  is  compulsory;  practically  as  much  so  as  if  re- 
quired by  statute.  This  fact  enables  the  trust  to  enforce  its  ex- 
actions. The  same  thing  would  happen  if  unemployment  in- 
surance was  made  compulsory  but  conducted  by  commercial 

1  As  Chairman  of  the  Social  Insurance  Committee  of  the  National  Convention  of 
Insurance  Commissioners  I  have  been  carrying  on  an  investigation  into  the  entire  sub- 
ject of  welfare  and  social  insurance  and  I  have  in  preparation  an  extensiv  report  on  the 
subject.  This  has  not  yet  been  publisht  but  extensiv  extracts  from  it  have  been  printed  as 
an  appendix  to  my  testimony  given  on  April  6,  1916,  before  the  Committee  on  Labor  of  the 
House  of  Representatives  in  relation  to  the  joint  resolution  to  create  a  commission  to  study 
social  insurance  and  unemployment.  (Hearing  before  the  Committee  on  Labor,  House  of 
Representatives,  Sixty-fourth  Congress,  First  Session  on  H.  J.  Res.  159,  April  6  and  11, 
1916.) 

Until  the  printed  supply  of  the  report  of  the  hearing  is  exhausted,  copies  of  it  can  be 
obtained  by  those  desiring  a  full  and  detailed  discussion  of  the  subject  by  applying  to  your 
Congressman. 


109 

interests,  and  the  same  reasons  require  that  unemployment  in- 
surance should  be  carried  on  by  the  state  or  United  States  as  a 
part  of  the  general  system  of  welfare  insurance.  I  believe  there 
would  be  little  hope  of  successful  unemployment  insurance  un- 
less it  was  carried  on  by  the  United  States.  Of  course,  there  will 
be  strenuous  objections  from  the  financial  and  insurance  inter- 
ests to  this  being  done  as  well  as  to  any  other  form  of  state  in- 
surance, but  these  objections  are  entirely  selfish  in  their  origin 
and  entitled  to  little  consideration  from  those  who  have  the  wel- 
fare of  the  nation  and  its  workers  really  at  heart.  The  argument 
is  the  same  as  that  used  1900  years  ago  by  the  idol  makers  against 
the  great  Apostle  Paul  in  the  riot  which  they  stirred  up  when  he 
preacht  against  idolatry  in  Ephesus. 

"Sirs,"  cried  their  leader,  Demetrius,  the  silversmith,  as  the 
climax  of  his  harangue,  "ye  know  by  this  craft  we  have  our 
wealth."! 

The  danger  to  their  source  of  easy  wealth  is  at  the  bottom 
of  all  the  outcry  of  the  insurance  interests  against  any  form  of 
state  insiu-ance. 

A  typical  example  of  these  miserably  selfish  appeals  appears 
in  a  recent  issue  of  one  of  the  most  widely  circulated  insurance 
periodicals  in  the  form  of  an  editorial  on  social  insurance  designed 
to  arouse  all  insurance  interests  against  it,  in  the  course  of  which 
the  writer  says: 

Doubtless  some  agents  may  find  employment  as  state  inspectors  and 
sleuths,  but  Othello's  occupation  will  be  gone  for  the  great  majority.  For 
these  reasons  every  insurance  man  in  every  branch  is  vitally  concerned  to  oppose 
the  "social"  propaganda  at  every  step.  For  his  own  safety  he  should  consider 
himself  in  the  advanced  trenches  whenever  state  insurance  is  proposed  in 
any  branch.  The  strongest  lever  exerted  for  any  of  the  "social"  branches 
is  that  it  will  "eliminate  expense,"  Expense  can  only  be  eliminated  in  one 
way.  That  is  by  taking  the  work  required  to  be  done  away  from  those 
now  engaged  in  doing  it,  and  throwing  it  compulsorily  on  every  citizen.' 

In  any  plan  of  unemployment  insiurance,  particular  attention 
should  be  given  to  prevention  of  fraud  and  imposition,  and  also 
to  prevent  the  steady  workers  from  being  taxt  to  support  the 

1  Acts,  19:25. 

«  Insurance  Field  (Life  Edition),  May  12,  1916,  p.  3. 


no 


idle  and  thriftless.     This  can  be  effectually  accomplisht  by  proper 
provisions  and  careful  administration. 

I  am  certain  that  by  careful  study  aided  by  experience,  a  plan 
of  unemployment  insurance  can  be  workt  out  which  will  be 
just  and  beneficial  to  both  employers  and  employes  and  of  im- 
mense advantage  to  the  community  in  general.  This,  together 
with  other  branches  of  welfare  insurance,  I  believe,  is  the  most 
important  group  of  questions  before  the  people  of  the  United 
States  to-day.  It  contains  more  promise  of  increasing  their 
welfare  and  diminishing  their  misery  than  any  other  movement 
I  know  of.  I  am  indeed  pleased  to  learn  from  the  interest  which 
has  been  manifested  in  your  discussions  here  to-day  on  these 
subjects,  that  your  Academy  is  taking  the  lead  in  the  movement 
for  social  justice  by  earnestly  taking  up  the  subject  of  welfare 
insurance,  which  I  regard  as  the  most  important  means  of  aiding 
in  this  great  work.  I  am  greatly  honored  in  having  been  invited 
to  address  you  concerning  it  and  hope  what  I  have  been  able  to 
say,  in  the  short  time  allotted  to  me,  may  cause  you  all  to  study 
and  investigate  it  still  farther.  Your  great  profession  has  already 
done  untold  good  to  humanity  by  mitigating  suffering  and  pre- 
venting disease,  and  it  has  the  opportunity  of  further  serving 
mankind  by  assisting  in  making  welfare  insurance  a  beneficent 
reality. 


THE  RELATION  OF  MEDICAL  BENEFITS  OF  HEALTH 
INSURANCE  TO  EXISTING  HEALTH  AGENCIES. 

By  B.  S.  Warren,  M.D.,  Washington,  D.  C,  Surgeon,  U.  S.  Public  Health  Service. 

Without  an  adequate  medical  service — clinical  and  pre- 
ventiv — health  insurance  will  fail  of  its  best  results.  By  pro- 
viding a  substantial  part  of  the  wages  and  medical  treatment 
during  sickness  it  will  no  doubt,  as  a  relief  measure,  prove  satis- 
factory to  the  welfare  workers,  the  employers,  and  the  employes, 
but  without  adequate  provision  for  the  prevention  of  disease 
it  will  not  prove  to  be  a  public  health  measure.  Each  of  the 
groups  of  people  mentioned  see,  at  close  range,  the  damage  done 
by  disease  and  that  the  damage  is  greatest  among  the  group  of 
low  paid  workers  who  are  least  able  to  bear  the  burden. 

The  welfare  workers'  field  lies  mainly  among  the  group  of  low 
paid  wage  earners  and,  in  their  feeling  of  helplessness  among 
so  much  suffering,  the  idea  of  health  insurance  has  come  like  a 
ray  of  hope  for  the  solution  of  problems  that  appeared  well- 
nigh  hopeless. 

The  employer  has  found  from  experience  of  idle  machines  or 
from  machines  running  at  lessened  output  by  inexperienced 
operators,  that  sickness  is  expensiv  and  whether  he  has  sought  to 
remedy  this  as  a  matter  of  economy  or  filanthropy  he  will 
find  in  health  insurance  a  business-like  method  of  meeting  this 
situation. 

The  employes  may  not  be  afraid  of  death,  they  may  not  be 
much  concerned  about  accidents,  ''but  they  dread  the  thought 
of  illness,"  and  will  find  that  "the  only  way  this  matter  can  be 
handled  properly  so  that  the  most  necessitous  will  be  provided 
for  is  thru  universal  compulsory  state  health  insurance." ^ 

That  group,  who  are  interested  in  bringing  about  industrial 
peace,  will  doubtless  find  in  health  insurance,  a  common  ground 
on  which  employer  and  employe  can  meet  in  agreement  and  thru 

1  Royal  Meeker,  Commissioner  of  Labor  Statistics,  U.  S.  Department  of  Labor,  Ad- 
dress before  International  Association  of  Industrial  Accidents  Boards  and  Commissions, 
Columbus,  Ohio.     The  Survey,  May  20,  1916,  p.  205. 


112 


these  agreements  they  have  reason  to  beheve  that  peace  in  other 
fields  will  be  promoted. 

In  this  way  health  insm-ance  will  have  wonderful  results  as  a 
relief  measure,  and  will  no  doubt  measure  up  to  the  expectations 
of  those  who  advocate  it  on  this  account.  But  as  stated  above, 
it  will  fail  of  its  best  results  if  an  adequate  medical  service — clin- 
ical and  preventiv — is  not  provided.  On  the  other  hand,  with 
proper  provision  for  such  a  service,  health  insurance  will  be  a 
public  health  measure  farther  reaching  than  any  that  has  ever 
yet  been  enacted  into  law.  It  is  on  this  account  that  it  attracts 
the  attention  of  health  authorities.  At  present  the  fight  for 
better  health  is  one  which  is  carried  on  at  a  great  disadvantage. 
Health  departments,  national,  state,  and  local,  and  volunteer 
health  organizations  are  all  suffering  from  the  lack  of  men  and 
money.  Men  trained  in  disease-prevention  are  too  few,  but  if 
health  agencies  had  regular  and  sufficient  appropriations  the  men 
would  soon  be  at  hand. 

In  this  connection  it  is  of  importance  to  present  some  estimate, 
of  the  sum  of  money  that  the  contributions  to  a  complete  health 
insurance  system  would  amount  to  each  year.  There  were  ap- 
proximately 30,000,000  wage  earners  in  the  United  States  ac- 
cording to  the  census  of  19 10.  It  has  been  tentatively  stated 
that  the  contributions  to  the  insurance  funds  would  not  have 
to  exceed  50  cents  per  week  per  employe.  According  to  these 
estimates  the  total  sum  contributed  annually  would  be  more 
than  three-quarters  of  a  billion  dollars.  It  therefore  becomes  a 
problem  as  to  the  best  method  to  cut  down  sickness  and  save  a 
large  proportion  of  this  enormous  sum.  All  health  agencies 
realize  that  much  sickness  can  and  should  be  prevented.  It 
will  be  to  these  preventiv  agencies  that  the  people  contribut- 
ing these  millions  will  sooner  or  later  turn  for  relief. 

Experience  with  workmen's  compensation  laws  has  clearly 
demonstrated  that  the  "safety  first"  movement  is  one  of  the  best 
results  of  these  laws.  Just  as  the  laws  which  fixt  the  price  and 
responsibility  for  industrial  accidents  resulted  in  "safety  first," 
just  so  surely  will  health  insurance  laws,  which  make  similar  pro- 
visions with  respect  to  sickness,  result  in  a  movement  for  disease- 


113 

prevention.  Furthermore,  the  demand  for  disease-prevention 
will  probably  be  as  much  greater  than  the  "safety  first"  move- 
ment as  the  loss  from  sickness  is  greater  than  that  from  accident. 

Why  then  provide  a  health  insurance  system  without  adequate 
machinery  for  disease-prevention?  If  one  of  the  principle  argu- 
ments for  the  measure  is  its  effects  in  promoting  health,  surely 
then  every  effort  should  be  made  to  bring  into  its  operation  the 
aid  of  the  health  agencies  of  the  country. 

Up  to  the  present  time  there  is  no  experience  in  this  or  foreign 
countries  which  has  been  satisfactory  as  to  the  provision  for 
proper  co-ordination  of  the  administration  of  the  medical  bene- 
fits with  other  health  agencies.  In  Germany  there  was  so  much 
friction  between  health  insurance  administrativ  bodies  and  the 
doctors  that  a  "doctors*  strike"  resulted;  this  strike  was  only 
temporarily  settled  by  a  compromise  known  as  the  "Berlin 
Agreement."  This  agreement  was  made  early  in  19 14;  the  war 
began  soon  afterward  and  interrupted  further  action.  In  Great 
Britain  the  health  insurance  act  provides  for  governmental 
administration  of  medical  benefits  and  the  free  choice  by  insured 
persons  of  doctors  registered  on  "the  panels."  This  provision 
and  the  acceptance  of  disabiUty  certificates  signed  by  physicians 
of  the  insured  persons,  choice  has,  however,  resulted  in  an  improper 
drain  upon  the  funds  and  it  is  freely  admitted  that  doctors  have 
been  entirely  too  complaisant  in  signing  certificates  of  disability. 

In  the  bills  introduced  into  the  several  state  legislatures  in 
this  country  the  German  plan  of  administration  of  medical  bene- 
fits has  been  followed  and  no  provision  has  been  made  for  corre- 
lating the  system  with  health  agencies. 

The  public  and  those  framing  health  insurance  laws  should 
realize  the  necessity  of  making  proper  provision  for  the  adminis- 
tration of  the  medical  benefits  so  that  the  best  results  may  be  ob- 
tained for  the  prevention  as  well  as  for  the  relief  of  diseases.  They 
should  profit  by  the  mistakes  made  in  the  German  and  English 
acts.  One  reason  for  the  mistakes  made,  is  the  lack  of  under- 
standing on  the  part  of  those  framing  the  laws.  They  treat  the 
whole  matter  as  the  doctor's  problem,  taking  it  for  granted  that 
all  doctors  of  medicine   are   doctors  of  public  health  and  have 


114 

made  no  provision  for  utilizing  health  agencies  except  possibly 
in  the  matter  of  the  prevention  of  tuberculosis. 

To  write  into  the  law  adequate  provisions  for  the  relief  and 
prevention  of  sickness,  the  law  makers  should  advise  with  doc- 
tors of  public  health  and  doctors  of  medicine  as  well  as  employers, 
employes,  and  welfare-workers.  Surely  some  plan  can  be  workt 
out  by  which  adequate  medical  and  surgical  relief  in  home  or 
hospital  can  be  provided,  one  by  which  the  doctors  will  receive 
every  inducement  to  render  his  best  services  in  the  relief  and  pre- 
vention of  sickness,  and  by  which  all  health  agencies  can  be  brought 
into  the  system  and  use  made  of  their  specialists  in  disease-pre- 
vention. 

The  following  outline  of  a  plan  for  bringing  about  proper  co- 
ordination between  health  insurance  systems  and  other  health 
agencies  was  adopted  by  the  Fourteenth  Annual  Conference  of 
State  and  Territorial  Health  Officers  with  the  United  States 
Public  Health  Service,  May  13-15,  1916: 

There  must  be  a  close  connection  of  the  administration  of  any  health  in- 
surance system  with  the  health  agencies  of  the  country  and  with  the  medical 
profession.  It  is  believed  that  this  can  be  done  along  three  lines:  (i)  By 
providing  efficient  staffs  of  medical  officers  in  the  federal  and  state  health 
departments,  to  carry  into  effect  the  regulations  issued  by  the  central  govern- 
ing boards  or  commissions;  (2)  by  providing  a  fair  and  sufficient  incentiv 
for  the  activ  co-operation  of  the  medical  profession;  and  (3)  by  providing  for  a 
close  co-operation  of  the  health  insurance  system  with  state,  municipal,  and 
local  health  departments  and  boards. 

Corps  of  Full-time  Medical  Officers. — In  view  of  the  experience  in  both 
Europe  and  America,  it  would  seem  best  to  place  the  administration  of  the 
medical  benefits  directly  under  governmental  agencies  and  to  insert  a  pro- 
vision that  no  cash  benefits  be  paid  except  on  the  certificate  of  medical  officers 
of  the  national  and  state  health  departments  acting  as  medical  referes  under 
the  regulations  of  the  central  governing  board  or  commission.  Such  medical 
officers  should  be  selected  according  to  civil  service  methods.  Since  these 
officers  are  the  representatives  of  the  health  departments  in  the  funds,  their 
selection  and  appointment  should  also  be  based  upon  their  knowledge  of 
preventiv  as  well  as  of  clinical  medicine.  After  a  probationary  period  of 
service  satisfactory  to  the  health  administration  they  should  be  given  per- 
manent appointment,  subject  to  removal  only  for  inefficiency  or  immoral 
conduct.  One  of  their  duties  should  be  to  examine  each  disabled  beneficiary 
and  keep  themselves  informed  as  to  the  progress  of  his  recovery.     It  is  need- 


"5 

less  to  say  that  the  referes  should  not  be  permitted  to  engage  in  private 
practice. 

Free  Choice  of  Registered  Physicians. — With  such  a  check  on  the  payment 
of  cash  benefits,  the  medical  and  siu-gical  treatment  provided  for  beneficiaries 
could  safely  be  left  to  the  physician  of  the  patient's  choice,  and  payment  made 
on  a  capitation  basis  regardless  of  whether  the  patient  was  sick  or  well,  after 
the  manner  of  the  English  national  insurance  act.  This  method  of  selection 
and  payment  of  physicians  for  the  medical  and  surgical  relief  would  offer 
every  incentiv  to  them  to  keep  their  patients  well  and  to  endeavor  to  please 
by  rendering  their  most  efficient  service. 

Hospitals  and  Dispensaries. — In  addition  to  the  provision  for  home  treat- 
ment by  the  physician  of  the  patient's  choice,  provision  should  be  made  for 
hospital  and  dispensary  treatment  and  to  this  end  hospital  and  dispensary 
imits  should  be  establisht  or  contracted  with,  where  the  very  best  medical 
and  surgical  service  would  be  available  for  all  insured  persons. 

Value  of  Such  Plan  in  Disease-Prevention. — The  greatest  value  of  such  a 
system  of  administration  of  the  medical  benefits  would  be  in  the  splendid 
opportunity  it  would  offer  for  preventing  disease  among  the  insured  persons 
and  their  families,  by  the  organized  corps  of  medical  officers,  and  the  im- 
proved medical  and  surgical  treatment.  It  would  be  thru  the  corps  of  full 
time  medical  officers  of  the  health  department  acting  as  referes,  that  the 
health  insurance  system  would  be  linkt  up  with  other  health  agencies.  It  is 
not  necessary  to  relate  here  the  advantages  which  would  arise  from  the!  visits 
of  such  specially  trained  men  into  the  homes  of  all  sick  persons.  Nor  is  it 
necessary  to  tell  how  these  officers,  acting  as  health  officers,  could  further 
lower  the  sick  rate.  The  objection  could  not  be  raised  that  such  a  corps 
would  be  too  expensiv.  It  would  not  require  more  than  one  such  medical 
officer  to  approximately  every  4,000  insured  persons  and  at  that  rate  they 
could  more  than  save  their  salaries  by  relieving  insurance  funds  from  paying 
unjust  claims.  Furthermore,  while  an  estimate  cannot  be  made  of  the 
amount  to  be  saved  by  their  efforts  in  the  way  of  lowering  the  sick  rate,  it  is 
safe  to  say  that  it  would  amount  to  many  times  more  than  the  sum  of  their 
salaries.^ 

With  such  a  system  funds  would  be  provided  and  every  existing 
health  agency  and  newly  created  agencies  could  be  utilized  and 
fitted  into  its  proper  place  and  all  work  together  without  duplica- 
tion of  effort.  Above  all  there  would  be  a  financial  incentiv 
given  to  each  interested  group  to  prevent  sickness. 

The  employer,  who  found  that  he  was  contributing  more  per 

1  This  description  of  plan  for  administration  of  medical  benefits  is  taken  from  the  re- 
port of  the  Standing  Committee  of  the  Conference  of  State  and  Territorial  Health  Oflficers 
with  the  United  States  Public  Health  Service. 


ii6 

employe  per  year  than  his  competitor,  would  doubtless  inquire 
into  the  cause  of  the  difference. 

The  employe,  who  learned  that  his  neighbor  working  in  the 
same  kind  of  trade  was  paying  less  dues  than  himself,  would  also 
be  very  likely  to  inquire  into  the  cause  of  the  difference. 

The  doctor,  who  found  his  patients  were  sick  so  much  that  he 
was  not  able  to  attend  as  many  insured  persons  as  his  brother 
doctor,  would  have  a  financial  incentiv  to  look  into  the  cause  of 
the  difference  and  remove  it. 

The  city  or  town,  which  found  that  a  neighboring  city  or  town 
was  providing  adequate  hospital  and  dispensary  treatment  for 
its  insured  persons  and  not  only  obtaining  more  efficient  diag- 
nosis and  treatment  but  obtaining  it  at  a  less  cost,  would  doubt- 
less establish  similar  institutions. 

The  state,  which  found  from  the  returns  that  its  tax  rate  for 
sickness  was  in  excess  of  a  neighboring  state,  would  have  reasons 
for  making  this  an  issue  in  the  next  election. 

The  United  States  Public  Health  Service,  when  the  reports, 
for  example,  showed  a  markt  difference  in  the  sick  rate  of  an  iron 
and  steel  town  in  Pennsylvania  as  compared  with  such  a  town 
in  Alabama,  would  be  very  likely  to  order  the  responsible  officers 
to  Washington  to  explain  the  differences. 

The  final  result  would  be  that  health  would  be  placed  on  a 
competitiv  basis  in  the  political  and  business  worlds.  This  too, 
after  providing  for  the  co-operation  of  all  the  agencies  for  the 
promotion  of  health  so  that  all  would  work  in  harmony,  and  form 
one  complete  health  machine. 

Above  all  there  would  be  a  financial  incentiv  to  all  interested 
groups  to  prevent  disease.  To  do  this  they  would  be  willing  to 
spend  money  realizing  that  it  would  be  a  good  investment.  At 
present  it  may  be  generally  recognized  that  to  spend  money  to 
prevent  disease  is  a  good  investment,  but  there  is  no  administra- 
tion whereby  the  ones  who  make  the  investment  can  be  sure  of 
obtaining  the  profits  when  earned.  Health  insurance  will  pro- 
vide this  and  what  is  more  to  the  point,  it  will  provide  the  money, 
there  will  be  over  three-quarters  of  a  billion  dollars  each  year 
for  the  relief  and  prevention  of  sickness.    This  will  eliminate 


117 

the  question  of  obtaining  appropriations,  which  now  takes  up 
much  of  the  time  of  all  health  organizations.  At  present  contri- 
butions and  appropriations  for  health  work  are  so  uncertain 
and  irregular  that  definit  plans  for  the  work  cannot  be  made 
and  carried  out  with  anything  like  the  degree  of  efficiency  and 
success  as  obtains  in  other  lines  of  business. 

With  sufficient  funds  and  the  machinery  at  hand  thru  which 
the  health  agencies  can  work  effectively  and  continuously  with 
the  insurance  agencies,  there  will  develop  a  system  of  research 
into  the  cause  of  sickness  as  has  never  been  seen  before. 

The  records  of  disease  will  be  so  complete  that  not  only  the 
immediate  diagnosis  will  be  known  but  also  the  working  and 
living  conditions  which  may  be  operating  as  remote  causes  of 
sickness.  All  will  be  brought  under  the  microscopic  observation 
of  the  trained  men  from  the  health  department — not  for  a  single 
day  but  for  each  day  in  the  year. 

It  is  in  this  particular  relation  that  a  health  insurance  system 
if  not  properly  correlated  with  health  agencies  will  fail  of  its 
greatest  benefits,  whereas  if  properly  correlated  it  will  prove 
to  be  a  public  health  measure  of  extraordinary  value  in  improv- 
ing the  health  and  efficiency  of  the  30,000,000  wage  earners  in 
the  United  States. 

DISCUSSION. 

Dr.  Robert  B.  Harkness,  Houghton,  Michigan  (read  by  Dr. 
Grayson) : 

To  cover  the  subject  of  workmen's  compensation,  a  recital  of  the  argu- 
ments for  and  against  should  properly  be  presented ;  it  would  seem  unnec- 
essary at  this  date  to  be  obliged  to  present  the  case  at  length ;  fathered  some 
35  years  ago  by  powerful  statesmen  largely  interested  for  political  reasons, 
a  realization  of  its  tremendous  value  was  gradually  forced  upon  people  gen- 
erally, and  in  the  following  years  it  has  become  a  part  of  the  laws  of  some 
forty  nations,  or  parts  of  nations,  including  about  two-thirds  of  the  states 
of  the  United  States.     Its  history  would  seem  to  establish  its  value. 

During  this  time  social  insurance  against  sickness  which  became  an  activ 
issue  about  the  same  time  as  workmen's  insurance,  has  made  slower  progress 
and  has  not  always  been  a  complete  success.  Its  value  cannot  be  doubted; 
statistics  presented  by  capable  and  unprejudiced  persons  are  conclusive 
and  the  arguments  advanced  in  its  favor  apparently  unanswerable.     Statis- 


ii8 

tics  and  argument  should  not  be  necessary  to  convince  the  man  who  comes 
in  contact  with  sickness  among  working  people  that  some  form  of  relief  is 
necessary  and  if  a  given  form  of  sickness  insurance  does  not  seem  to  be  per- 
fectly suited  to  our  conditions,  nevertheless  those  at  present  suggested  have 
a  minimum  of  flaws  and  should  be  supported. 

There  can  be  no  doubt  that  people  want  some  form  of  insurance  against 
sickness — the  rush  to  join  lodges  that  promise  medical  attendance  in  almost 
any  form  is  evidence  of  this ;  this  type  of  insurance  is  not  available  to  the  per- 
son most  in  need  of  it — that  is,  the  man  whose  wages  are  barely  equal  to  his 
necessary  expenditures  and  who  prefers  to  trust  to  luck  rather  than  submit 
himself  and  family  to  the  necessary  hardship  which  the  payment  of  monthly 
dues  to  such  a  society  would  necessitate. 

^'The  matter  of  medical  attention  as  furnished  by  lodges  has  received  con- 
sideration by  the  medical  societies;  many  of  them  are  on  record  as  opposed 
to  it  and  with  some  reason.  One  must  realize,  however,  that  this  is  a  phase 
of  social  insurance,  represents  the  trend  of  the  times,  and  should  be  controlled 
rather  than  violently  opposed;  this  type  of  practise  properly  conducted  has 
much  to  recommend  it  in  spite  of  its  limitations. 

Social  insurance  against  accident  and  sickness  has  as  an  important  aim 
the  decrease  of  sickness  and  accidents  by  impressing  upon  the  employer  the 
saving  to  him  brought  about  by  this  decrease;  by  the  method  of  carrying  out 
the  workmen's  compensation  in  this  country  this  aim  is  largely  defeated; 
the  employer  insures  himself  with  a  liability  company,  pays  his  premiums,  and 
thereafter  is  not  compelled  to  give  much  heed  to  accidents  if  he  does  not  care 
to  do  so. 

It  is  becoming  customary  to  have  a  thorough  physical  examination  of  men 
applying  for  work  with  careful  concerns;  men  not  physically  perfect  even 
though  fit  for  the  job  applied  for  are  usually  rejected.  Until  recently  a  one- 
eyed  man  had  extreme  difficulty  in  getting  work  because  there  had  been  no 
authoritativ  answer  in  this  State  to  the  question  of  the  liability  in  his  case 
if  he  should  lose  the  remaining  eye ;  that  is,  should  compensation  be  upon  the 
basis  of  the  loss  of  a  single  eye  or  on  total  loss  of  sight? 

The  definition  of  "disability"  in  drafts  of  health  insurance  acts  before 
various  legislatures  is  given  as  "inability  to  pursue  the  usual  gainful  occupa- 
tion;" under  this  definition  the  man  who  has  received  an  injury  and  is  so  far 
recovered  as  to  work  at  something  else  but  not  at  his  original  job  may  remain 
technically  disabled.  A  case  of  this  sort  under  the  compensation  law  has 
come  to  my  knowledge  recently;  a  man  who  had  a  broken  leg  has  so  far  re- 
covered as  to  be  free  from  pain  and  while  incapable  of  working  at  his  old  job 
which  requires  standing  all  day,  is  capable  of  working  at  an  equally  gainful 
job;  he  prefers  to  do  nothing,  or  work  about  his  house,  and  draw  compensa- 
*'  tion.  The  definition  of  "disability"  might  well  be  "inability  to  pursue  the 
usual  or  equally  gainful  occupation." 

The  important  question  of  malingering  should  receive  a  great  deal  of  con- 


119 

sideration;  there  can  be  no  doubt  that  the  amounts  paid  under  workmen's 
compensation  acts  would  be  startlingly  less  if  this  unpleasant  factor  could 
be  eliminated. 

Any  safeguard  which  may  be  erected  against  malingering  is  protecting 
a  cident  and  sickness  insurance  against  what  is  probably  the  greatest  menace 
to  its  successful  operation. 

Dr.  John  L.  Heffron,  Syracuse: 

I  am  not  competent  to  discuss  the  papers.  I  wish,  however,  to  express  my 
gratitude  to  those  who  have  taken  part  in  the  program  for  coming  here  and 
presenting  papers  which,  it  seems  to  me,  combined,  would  make  about  the 
best  text-book  on  welfare  insurance  that  it  would  be  possible  to  secm-e.  I 
think  we  have  been  strongly  imprest  with  the  fact  that  insurance  is  a  science 
and  that  to  be  intelligent  on  the  subject  of  insurance  against  these  various 
forms  of  disability  we  must  put  ourselves  into  a  studious  frame  of  mind 
and  inform  ourselves  in  regard  to  the  principle  of  insurance  and  the  various 
methods  of  administration  of  insiurance  which  have  been  carried  out  effec- 
tively here  and  in  foreign  nations. 

The  number  of  problems  represented  by  these  papers  is  very,  very  great. 
The  question  of  administration  of  insurance  is  one  of  the  very  greatest  im- 
portance. The  splendid  paper  of  Dr.  Warren,  in  which  a  way  out  has  been 
suggested,  is  of  very  great  value.  It  is  in  contrast  with  statements  which 
I  have  lately  heard  in  regard  to  the  administration  of  insurance  against  sick- 
ness and  which  were  to  the  effect  that,  if  such  insurance  should  be  adopted 
in  the  various  states,  the  administration  of  the  insurance  ought  to  be  turned 
over  to  experts  in  insurance.  I  suppose  it  is  correct,  that  expert  administra- 
tion is  essential  to  success,  but  that  need  not  mean  that  social  insurance 
should  be  turned  over  to  insiurance  companies.  One  of  the  difficulties  in 
the  State  of  New  York  has  been  the  division  of  the  burden  of  the  insurance 
between  the  employer,  the  employe  and  the  state.  I  suppose  Dr.  Andrews 
knows  of  experiments  being  tried  in  this  connection  in  various  large  indus- 
trial concerns,  I  happened  to  be  in  Akron  this  winter  at  the  Goodrich 
manufactory  where  they  employ  16,000  people  and  have  1600  employes  in 
the  offices.  The  head  of  that  business  told  me  that  last  November  they 
inaugmrated  at  their  own  expense  a  complete  system  for  the  care  of  the  health 
of  their  employes  and  that  up  to  the  time  I  was  there  the  benefits  which  had 
accrued  to  the  company  had  not  only  met  the  expenses  of  this  care  but  had 
exceeded  it  by  a  considerable  sum.  They  did  not  feel,  therefore,  the  neces- 
sity of  putting  any  of  the  burden  upon  the  employe  or  the  state. 

As  a  result  of  such  a  condition  of  affairs  it  is  the  town's  comment  that  a 
man  cannot  get  a  place  in  the  Goodrich  concern  unless  somebody  dies.  I 
think  in  all  probability  that  concern  is  not  the  only  one  carrying  out  that 
experiment  on  their  own  hook. 

I  am  particularly  grateful  for  this  discussion  and  for  this  splendid  series 


I20 

of  papers  upon  this  subject,  and  I  wish  in  this  connection  to  express  my 
gratitude  to  Surgeon-General  Blue  for  very  willingly  consenting  to  have  Dr. 
Warren  come  here  and  present  this  valuable  paper. 

Dr.  J.  E.  Tuckerman,  Cleveland: 

These  papers  are  evidence  of  a  very  healthful  state  of  mind.  The  medical 
profession,  at  least,  so  far  as  the  rank  and  file  are  concerned,  has  been  rather 
backward  in  realizing  that  certain  types  of  insurance  were  inevitable.  Some 
of  us  in  Ohio  five  years  ago  endeavored  to  get  our  associates  to  realize  that 
workmen's  compensation  was  coming.  We  could  not  get  them  to  see  it, 
and  consequently  the  profession  is  suffering  the  penalty  of  this  negligence. 
That  penalty  is,  of  course,  that  while  we  have  a  fairly  good  law,  we  find 
that  no  matter  how  admirable  a  law  may  be,  its  administration  may  be 
such  that  the  best  results  are  not  obtained.  It  was  a  mistake  to  assume 
that  physicians  generally  were  going  to  be  paid  their  small  fees,  and  a  cutting 
down  of  bills  has  caused  much  hard  feeling.  So  generally  is  this  so  in  the 
larger  cities  that  specialists  are  refusing  to  cooperate  in  consultation  on 
certain  cases  of  industrial  accident,  particularly  of  the  eyes.  Altho  the  law 
as  written  does  in  large  measure  protect  the  employer  against  the  suits  after- 
ward, it  in  no  way  gives  any  protection  to  the  physician  who  may  be  sub- 
jected to  suit  for  alleged  malpractice. 

Personally,  I  have  felt  that  industrial  insurance  should  be  a  direct  charge 
against  the  industry.  I  am  not  so  sure  that  sickness  insurance  should  also 
be  a  charge  against  the  industry;  probably  a  man  should  pay  from  his  earn- 
ings a  small  portion,  not  necessarily  one-half,  for  the  purpose  of  getting  his 
activ  cooperation. 

I  am  interested  to  know  whether  Dr.  Andrews  has  discovered  any  ten- 
dency on  the  part  of  the  industrial  insurance  companies  to  oppose  the  plan 
suggested  by  him,  inasmuch  as  his  statement  shows  that  it  would  take  away 
from  them  and  give  to  the  state  a  considerable  amount  of  business  which  the 
companies  now  have. 

These  papers  would  have  been  incomplete  without  the  paper  which  we 
heard  last.  It  is  the  first  time  I  have  heard  given  any  comprehensiv  scheme 
whereby  the  activ  cooperation  of  the  practicing  physician  could  be  obtained 
in  forwarding  the  aim  of  health  measures  such  as  we  have  in  mind.  I  judge 
the  idea  is  to  have  the  physician  paid  according  to  the  number  of  individuals 
treated  and  not  according  to  the  case  or  nature  of  the  particular  service.  I 
can  see  no  way  to  get  away  from  that  final  solution.  The  important  thing  is 
for  physicians  to  recognize  that  the  problem  must  be  met  and  to  meet  it 
in  the  spirit  of  cooperation  rather  than  of  opposition. 

One  of  the  other  papers  brought  up  a  point  which  interested  me  not  a  little. 
Mr.  Potts  mentioned  that  there  were  certain  underlying  elements  other  than 


121 

the  mere  question  of  health  insurance  which  had  to  do  with  the  question  of 
unemployment.  Certainly  there  is  no  greater  loss  to  a  community  than  the 
loss  of  a  man's  labor.  Machinery  can  be  restored,  but  a  day's  labor  gone  is 
absolutely  lost  to  the  community.  I  was  much  interested  to  note  that  Mr. 
Potts  advocated  something  that  was  indicated  a  number  of  years  ago,  which 
shows  that  the  world  does  move.  A  certain  gentleman  from  Ohio,  heading 
what  was  known  as  "Coxey's  Army,"  marcht  to  Washington  for  no  other 
purpose .  whatever  than  to  induce  the  United  States  Government  to  take 
notice  of  the  fact  that  it  would  be  a  good  thing  in  times  of  industrial  depres- 
sion to  employ  the  unemployed  upon  public  works  of  permanent  charac- 
ter. 

I  do  not  care  to  take  up  the  time  of  this  body  upon  the  question  of  taxa- 
tion, but  there  must  be  a  changed  attitude  on  the  part  of  and  a  study  by 
physicians,  and  other  professional  men  of  the  question  of  taxation.  None 
of  these  plans  can  be  put  into  operation  without  a  proper  solution  of  the  prob- 
lem of  taxation.  Such  funds  as  the  state  shall  contribute  must  be  so  raised 
as  not  to  penalize  the  individual  or  firm  engaged  in  activ  production.  It 
is  a  curious  system  which  makes  it  possible  that  a  man  who  builds  a  building 
and  employs  labor  should  be  immediately  penalized  for  having  made  a  pub- 
lic improvement  and  having  rendered  a  public  service  by  increasing  the  op- 
portunity for  employment. 

Dr.  George  A.  Hare,  Fresno,  Cal. : 

I  do  not  think  that  the  American  Academy  of  Medicine  or  any  other  or- 
ganization has  ever  listened  to  a  more  intelligent  discussion  of  the  broad 
aspects  of  insurance  than  we  have  had  presented  to-day.  To  me  the  sub- 
ject has  been  an  intensely  interesting  one.  Upon  the  western  coast  this 
question  is  claiming  a  great  deal  of  attention,  and  the  discussion  this  after- 
noon has  been  exceedingly  direct  and  edifying. 

Dr.  Van  Sickle,  closing: 

There  are  four  great  bodies  in  the  United  States  concerned  in  this  social 
study:  (i)  The  State,  in  which  we  might  include  the  United  States  Govern- 
ment; (2)  Capital;  (3)  Labor;  (4)  The  medical  profession.  These  various 
papers  touch  vitally  one  of  these  four  organizations.  They  have  brought  out 
things  which  we  as  a  small  body  should  not  keep  to  ourselves;  the  literature 
should  be  given  the  widest  publicity.  I  feel  that  in  Dr.  Andrews'  statement 
we  have  something  which  the  profession  at  large  must  appreciate,  that  the 
health  insurance  shall  not  only  take  in  the  employer,  employe  and  insurance 
carrier,  but  that  there  shall  be  in  these  conferences  a  representativ  of  the 
medical  profession,  so  that  these  four  bodies  shall  be  represented. 

Dr.  Andrews'  suggestion  of  social  insurance  against  sickness  would  cer- 
tainly reliev  the  state  and  local  municipaUties  of  a  large  amount  of  expense 
from  pauperism.     If  social  insurance  is  to  operate  upon  the  scheme  of  the 


122 

smallest  cost  to  the  greatest  number  we  must  have  cooperation.  Dr.  An- 
drews brought  to  our  minds  the  fact  that  there  is  a  continuous  demand  for 
cooperation  of  medical  men  which  can  be  brought  about  only  by  action  of 
all  the  bodies.  We  have  a  lot  of  men  who  are  like  workmen  in  regard  to  the 
labor  union,  medical  men  who  do  not  belong  to  these  bodies.  These  are  the 
men  whom  we  must  get  together  for  discussion  of  the  subject.  This  audience, 
while  small,  has  an  opportunity  to  do  good  missionary  work  in  this  field. 

Dr.  Andrews,  closing: 

I  have  noted  three  or  four  points  which  I  shall  mention  without  going  into 
the  matter  at  length.  It  is  very  significant,  I  think,  that  Dr.  Van  Sickle, 
coming  from  Pennsylvania,  has  made  out  strongly  the  point  that  the  adminis- 
trativ  commissions  should  be  given  greater  discretion  in  granting  additional 
medical  aid.  This  is  especially  true  in  Pennsylvania  under  workmen's  com- 
pensation. No  other  state  is  limited  so  severely,  to  $25  and  two  weeks 
for  medical  aid.  That  allowance,  of  course,  is  so  utterly  inadequate  that  all 
friends  of  workmen's  compensation  regret  seeing  Pennsylvania  pass  such 
a  bill.  Medical  aid  ought,  I  believe,  to  be  "reasonable."  The  administra- 
tiv  commission  ought  to  have  the  power  to  say  that  all  the  medical  aid  neces- 
sary— and  necessary  is  reasonable — should  be  given,  and  not  a  two  weeks' 
or  $25  maximum. 

As  Dr.  Van  Sickle  has  said,  the  smallness  of  the  medical  fee  under  social 
insurance  is  counterbalanced  by  the  fact  that  payment  is  certain  when  the 
plan  is  properly  workt  out.  In  the  third  edition  of  the  tentativ  health  in- 
surance bill  of  the  Association  for  Labor  Legislation  the  medical  experts 
who  are  cooperating  with  us  in  drafting  the  measiure  discuss  this  question 
of  remunerating  physicians.  These  medical  experts  have  not  reacht  definit 
conclusions,  but  offer  for  discussion  foiu*  possible  methods,  including  a  com- 
promise, which  has  workt  well  elsewhere,  between  the  capitation  and  the  visita- 
tion systems.  Under  this  plan  a  total  sum,  calculated  on  a  per  capita  basis, 
is  distributed  among  physicians  in  accordance  with  the  services  rendered 
by  each.  This  plan  seems  to  combine  the  advantages  of  both  systems  men- 
tioned, and  to  counteract  some  of  their  obvious  disadvantages.  As  Dr. 
Alexander  Lambert,  chairman  of  the  social  insurance  committee  of  the  Amer- 
ican Medical  Association,  points  out,  the  plan  presents  a  known  charge 
on  the  insurance  funds,  makes  it  possible  for  physicians  to  check  those  few 
of  their  colleagues  who  might  make  unnecessary  visits,  and  may  prove  a 
financial  stimulus  to  preventiv  medicine,  since  the  fewer  visits  the  entire  body 
of  physicians  is  called  upon  to  make  the  more  they  will  be  paid  for  each  visit. 

Dr.  Warren,  who  has  been  doing  excellent  work  in  public  health  matters, 
approaches  the  problem  of  medical  control  under  health  insurance  from  the 
standpoint,  as  he  frankly  states,  of  a  public  health  officer.  There  are,  how- 
ever, other  groups,  outside  of  the  public  health  officers,  who  take  a  different 
view  of  the  manner  in  which  health  insurance  should  be  administered.     Many 


123 

physicians  are  not  yet  willing  to  put  the  whole  matter  into  the  hands  of  the 
health  officers,  and  as  one  speaker  has  said,  to  do  so  might  in  some  places 
lead  to  an  undesirable  association  with  politics.  In  the  opinion  of  many 
prominent  medical  men,  the  work  of  examining  claimants,  issuing  certificates 
of  disability,  and  supervising  medical  care  generally,  is  best  performed  by 
medical  officers  employed  by  the  insurance  carriers  themselves. 

A  very  interesting  statement  was  made  by  another  speaker  about  an  es- 
tablishment fund  in  a  concern  in  Akron,  Ohio.  Investigators  have  records 
of  a  large  number  of  such  enterprises.  We  must  realize,  however,  that  these 
funds  establisht  by  the  employer  here  and  there  all  over  the  country  are  not 
going  to  reach  the  worst  part  of  the  problem.  Only  the  most  prosperous 
employers  are  likely  to  feel  that  they  can  assume  this  service.  Then,  too, 
there  is  the  disadvantage  of  the  physical  examination  instituted  by  the  em- 
ployer, which  has  become  a  very  vital  issue  in  this  country.  Under  work- 
men's compensation,  for  instance,  many  employers  hire  a  physician  to  make 
physical  examinations  of  applicants  for  work.  The  employer  thus  has  in 
his  hands  information  which  enables  him  arbitrarily  to  hire  and  to  fire.  Many 
times,  for  example,  it  may  be  said  that  there  is  something  the  matter  with 
a  workman's  heart,  whereas  it  may  be  that  the  man  in  charge  is  more  ac- 
tivly  interested  in  preventing  union  organization  in  the  plant  than  in  safe- 
guarding the  physical  condition  of  the  applicant.  In  health  insurance, 
on  the  contrary,  with  employer  and  employe  paying  equal  amounts,  the  situa- 
tion no  longer  exists  under  which  the  employer's  hired  physician  has  all  the 
say  and  the  employe  no  say.  The  employe  has  an  equal  voice,  and  that  to 
my  mind  is  the  only  answer  to  the  objection  to  physical  examinations. 

In  conclusion,  it  seems  clear  from  the  discussion  this  afternoon  that  we  are 
on  the  way  toward  greater  cooperation  among  all  of  the  different  interests 
in  this  matter  and  are  working  out  a  practical  plan  for  compulsory  health 
insurance.  I  believe  that  is  the  thing  we  should  emphasize  now.  Let  us 
get  together,  present  our  ideas,  and  draft  a  bill  which  next  year  we  can  all 
get  behind  and  be  proud  of. 

Mr.  Potts,  closing: 

I  do  not  feel  that  I  can  add  to  anything  that  has  been  said.  I  am  fully  in 
accord  with  the  spirit  of  the  meeting;  the  cooperation  suggested  is  that  which 
brings  success  to  all  undertaking.  I  appreciate  your  calling  me  again,  but  I 
feel  I  can  say  nothing  fiurther.     Thank  you. 

Dr.  Warren,  closing: 

I  fear  I  did  not  make  myself  exactly  clear  about  the  Health  Department 
from  what  Dr.  Andrews  said.  I  did  not  propose  to  put  any  great  part  of  the 
administration  of  the  medical  benefits  under  the  health  departments.  I 
would  provide  for  federating  all  of  the  local  funds  with  a  federated  direc- 
torate composed  of  equal  number  of  employers  and  employes  in  certain  dis- 


124 

tricts,  such  as  he  has  outlined  in  his  plan,  and  let  them  as  a  federated  body 
administer  the  medical  benefits  instead  of  the  local  fund.  In  other  w6rds, 
we  would  have  a  wholesale  medical  benefit  with  less  overhead  expense  than 
would  obtain  by  permitting  each  local  fund  to  operate  independently.  The 
only  way  in  which  I  would  link  up  the  health  department  would  be  by  de- 
tailing to  those  federated  bodies,  medical  officers  of  health  departments 
to  act  as  medical  referes  and  relieve  the  practicing  physician  of  the  responsi- 
bility of  signing  the  disability  certificate.  A  plan  somewhat  similar  to  this 
is  followed  by  the  Public  Health  Service  and  the  Immigration  Service  in  which 
our  medical  officer  issues  the  certificate  of  disability.  Such  certificate  is  re- 
ferred to  the  administrativ  board  which  passes  on  the  question  of  admitting 
or  of  deporting  the  immigrant.  That  plan  suggested  to  my  mind  the  prac- 
ticability of  its  being  used  to  solve  this  problem.  The  medical  officer,  there- 
fore, from  the  health  department  would  have  little  to  say  in  the  administra- 
tion of  funds,  but  would  advise  upon  disability  and  issue  the  certificate. 
The  insured  persons  would  have  the  right  of  appeal  to  the  federated  body 
and  to  the  Commissions.  The  doctors  of  the  public  health  department 
could  also  act  as  advisors  to  the  federated  body  in  the  matter  of  disease-pre- 
vention. I  did  not  mean  that  the  health  department  should  take  over  the 
administration.  As  to  the  statement  of  Dr.  Andrews  that  in  medical  mat- 
ters "pus  and  politics"  went  hand  in  hand,  I  will  say  that  with  proper  efficiency 
tests  prior  to  appointment  and  as  often  thereafter  as  may  be  necessary  to 
maintain  the  medical  corps  at  the  highest  level  of  effectivness,  I  believe  we 
can  avoid  the  defects  he  points  out.  I  feel  certain  that  this  plan  of  appoint- 
ment in  an  important  executiv  department  of  the  state  is  calculated  to  ob- 
tain better  medical  referes  than  the  method  proposed  in  the  model  bill  in 
which  it  is  proposed  that  the  local  carriers  each  employ  a  doctor,  in  which 
local  politics  is  more  liable  to  bring  all  of  the  evils  he  dreads  in  the  health 
department.  His  method  would  also  lose  all  of  the  advantages  of  a  mobile 
corps  formation.  Furthermore,  doctors  employed  by  the  carriers  could  not 
act  as  referes,  because  they  would  be  the  employes  of  one  of  the  parties 
at  interest  and  liable  to  some  bias  on  that  account. 


THE  NEW  YORK  STATE  SANITARY  CODE,    HOW 
ENACTED— ITS   SCOPE  AND  LEGAL  STATUS. 

By  Hermann  M.  Biggs,  M.D.,  State  Commissioner  of  Health,  Albany,  N.  Y. 

The  International  Congress  on  Tuberculosis,  which  was  held 
in  Washington  in  the  autumn  of  1908,  gave  a  new  impetus  to  the 
campain  for  the  prevention  of  tuberculosis.  Prior  to  that  time 
a  large  amount  of  important  pioneer  work  had  been  carried  on 
in  the  City  of  New  York  under  the  direction  of  its  Department 
of  Health.  In  1887  that  department  issued  its  first  printed  circu- 
lar on  the  cause  and  prevention  of  tuberculosis  for  distribution 
among  families  and  in  homes  where  there  were  persons  affected 
with  the  disease.  In  1894  a  resolution  was  past  which  required 
the  reporting  of  cases  of  tuberculosis  from  institutions  and  in 
1897  this  was  extended  to  require  the  reporting  of  all  cases.  These 
requirements  were  made  by  amendments  to  the  Sanitary  Code 
of  the  City  of  New  York. 

With  the  new  knowledge  and  new  enthusiasm  given  by  the 
International  Congress  increast  activity  was  stimulated  in  the 
tuberculosis  problem,  not  only  in  New  York  City,  but  also  thru- 
out  the  State  of  New  York.  An  important  factor  in  the  campain 
then  inaugurated  was  the  New  York  State  Charities  Aid  Associa- 
tion, which,  in  co-operation  with  the  New  York  State  Depart- 
ment of  Health,  prepared  a  number  of  exhibits  on  tuberculosis 
and  held  a  large  number  of  public  meetings  in  numerous  localities 
thruout  the  State.  As  a  result  of  this  campain  many  local  com- 
mittees were  organized  and  the  interest  and  support  of  many 
prominent  officials  and  citizens  obtained. 

This  educational  activity  created  an  increast  interest  in  all 
fases  of  public  health  work.  It  was  soon  realized  that  in  the 
prevention  of  tuberculosis  many  sanitary  factors  must  be  con- 
sidered. Many  persons  became  interested  and  sought  to  eradicate 
other  associated  causes  of  the  disease  by  improving  the  care  of 
the  delicate  child,  by  improving  the  milk  supply  to  prevent  in- 


126 

fection  from  cattle,  by  better  housing,  and  by  generally  improving 
conditions  in  the  factory  and  home.  During  this  campain  the 
fact  was  first  fully  realized  by  the  officials  of  the  State  Health 
Department  and  by  members  of  various  citizens'  committees 
thruout  the  State,  that  the  health  boards  (numbering  more  than 
1200)  of  every  city,  village  and  town  had  the  power  to  enact 
their  own  sanitary  regulations,  but  that  such  regulations  in  many 
places  had  never  been  enacted,  or  if  enacted  at  all  only  existed 
in  theory  on  the  minutes  of  the  Common  Council  or  the  local 
Board  of  Health,  and  were  actually  never  enforced  nor  utilized. 
In  some  of  the  more  progressiv  cities  comprehensiv  sanitary 
codes  had  been  establisht  and  were  regularly  enforct.  As  a  re- 
sult of  this  situation  in  many  municipalities  the  health  officer 
acted  as  he  saw  fit,  and  the  sanitary  administration  really  depended 
upon  his  personal  intelligence  and  efficiency. 

An  effort  was,  therefore,  made  in  the  early  part  of  19 13  to  se- 
cure the  appointment  by  the  Governor  of  a  Commission  for  the 
study  and  revision  of  the  public  health  law  of  the  State.  Such 
a  commission  was  appointed  by  Governor  Sulzer,  of  which  I^ 
had  the  honor  to  be  Chairman.  Others  serving  on  this  Commis- 
sion were  the  Hon.  John  A.  Kingsbury,  now  Commissioner  of 
Charities  of  the  City  of  New  York ;  the  Hon.  Homer  Folks,  former 
Commissioner  of  Charities  of  the  City  of  New  York,  now  Secre- 
tary of  the  State  Charities  Aid  Association;  Dr.  John  C.  Otis, 
of  Poughkeepsie ;  the  Hon.  Ansley  Wilcox,  of  Bufifalo,  and  Miss 
Adelaide  Nutting,  of  Teachers  College,  Columbia  University. 
In  the  investigations  made  and  hearings  held  by  the  Commission 
during  the  year  of  19 13  one  of  the  most  striking  features  was  the 
fact  already  alluded  to;  namely,  that  there  was  no  uniformity 
in  the  sanitary  regulations  then  in  force  thruout  the  State. 

In  drafting  a  sweeping  revision  of  the  Public  Health  Law  it 
was  recommended  that  there  be  establisht  a  Public  Health  Council 
of  seven  members,  one  of  whom  should  be  the  Commissioner  of 
Health,  the  other  six  members,  appointed  by  the  Governor, 
each  to  serv  for  a  period  of  six  years.  The  Legislature  accepted 
this  recommendation  and  in  the  revision  of  the  Public  Health 

»  Dr.  Biggs'. 


127 

Law,  now  known  as  Chapter  559  of  the  Laws  of  19 13,  then  adopted, 
empowered  the  Governor  to  appoint  such  a  PubHc  Health  Council 
and  gave  it  power  to  enact  sanitary  regulations  having  all  the  force 
and  effect  of  law  thruout  the  State  outside  of  New  York  City. 
It  was  expressly  stipulated  that  the  Council  should  have  no  ap- 
pointiv  or  administrativ  powers. 

The  political  controversies  which  developt  dtu-ing  and  after 
the  legislativ  session  of  19 13  postponed  for  a  considerable  time 
the  appointment  of  a  Commissioner  of  Health,  altho  the  Council 
was  appointed  and  held  its  first  meeting  in  October,  19 13.  Still 
little  work  was  done  on  the  Sanitary  Code  until  January,  19 14. 
The  Public  Health  Council  then  began  its  work  in  earnest  and 
after  several  months  promulgated  the  first  two  chapters  of  the 
Sanitary  Code,  relating  to  the  communicable  diseases.  These 
regulations  for  the  control  of  communicable  diseases  deal  chiefly 
with  the  method  of  reporting,  the  period  of  isolation  and  various 
other  procedures  necessary  to  prevent  the  spread  of  infection  and 
to  control  the  infected  individuals. 

From  time  to  time  additions  have  been  made  to  the  Code,  a 
chapter  was  added  providing  for  the  grading  of  the  milk  supplies 
of  all  the  municipalities  of  the  State;  a  chapter  regulating  the 
practice  of  midwifery  by  midwives;  a  chapter  regulating  the 
establishment  and  sanitation  of  labor  camps;  a  chapter  providing 
the  procedure  for  the  investigation  and  abatement  of  nuisances, 
and  a  miscellaneous  chapter  regulating  the  sanitary  conditions 
of  barber  shops,  chiropodists,  and  prohibiting  the  use  of  the  common 
towel  or  common  drinking  cup  in  public  places.  The  Council 
has  now  under  consideration  the  enactment  of  regulations  for  the 
control  of  water  supplies  and  a  number  of  other  important  prob- 
lems. 

The  importance  of  a  uniform  Sanitary  Code  which  applies 
to  every  part  of  New  York  State  except  the  City  of  New  York 
cannot  be  overestimated.  It  enables  the  local  health  officer  to 
have  regulations  enforct  with  the  backing  and  support  of  a  State 
Law,  the  violation  of  which  may  be  either  a  misdemeanor,  or  in 
some  cases  a  civil  action  may  be  instituted  for  a  violation  thru  the 
office  of  the  Attorney-General  of  the  State. 


128 

In  the  various  localities  of  the  State,  especially  in  the  rural  dis- 
tricts, it  was  not  previously  possible  to  compel  the  enforcement  of 
sanitary  regulations  owing  to  the  close  relationships  which  exist 
between  the  health  officer,  who  was  perforce  a  practicing  physician, 
and  who  had  to  enforce  sanitary  regulations  upon  patients  who 
might  themselves  be  high  in  authority  in  the  administration  of 
the  city,  town  or  village  in  which  he  resided.  The  health  officer 
can  now  say,  "I  have  no  other  course  to  pursue.  The  State 
Sanitary  Code  requires  it,"  and  he  can  also  state  that  if  it  is  not 
enforct  the  State  will  compel  him  to  enforce  it  or  send  a  repre- 
sentativ  to  see  that  it  is  enforct.  This  gives  great  moral  sup- 
port to  the  local  health  officer  and  enables  him  to  accomplish  far 
more  than  he  could  under  the  old  system. 

There  are  many  objections  to  and  criticisms  of  the  Sanitary 
Code.  Complaint  has  been  made  by  laymen  and  legislators  that 
the  regulations  were  too  stringent  and  that  their  enactment  by 
an  appointed  body  was  unconstitutional  and  was  the  sole  preroga- 
tiv  of  the  Legislature.  In  the  development  of  our  modern  sys- 
tems of  government  often  it  is  not  possible  for  the  Legislature  to 
go  into  the  necessary  detail  as  to  the  methods  of  procedure  and 
it  has  become  customary  for  the  Legislature  to  grant  power  to 
various  boards  and  commissions  to  enact  regulations.  This  is 
true  in  the  State  of  New  York  in  the  Department  of  Agriculture, 
Public  Service  Commission,  Industrial  Board  of  the  Labor  De- 
partment and  in  many  other  departments  of  the  government. 
An  attempt  was  made  during  the  legislativ  session  of  19 15  to  de- 
clare the  Sanitary  Code  null  and  void  until  its  provisions  should 
be  subsequently  approved  by  the  Legislature.  This  attempt  was 
defeated. 

In  considering  the  amendments  adopted  by  the  Legislature  in 
i9i3>  giving  the  Public  Health  Council  power  to  enact  sanitary 
regulations,  this  matter  of  legislativ  authority  was  given  careful 
consideration  and  it  was  believed  that  ample  precedent  existed 
for  this  purpose. 

In  1886  the  Legislature  of  the  State  of  New  York  created  a 
Metropolitan  Board  of  Health  for  the  sanitary  control  of  the  City 
of  New  York  (then  situated  entirely  within  the  County  of  New 


129 

York)  and  the  counties  of  Kings,  Richmond  and  Westchester, 
and  the  towns  of  Newtown,  Flushing  and  Jamaica  in  the  County  of 
Queens.  When  this  Board  was  created  it  was  given  power  to 
enact  sanitary  regulations  for  the  control  of  the  public  health 
in  the  entire  Metropolitan  District.  One  of  the  first  regulations 
enacted  by  that  Board  prohibited  the  driving  and  slaughtering 
of  cattle  within  certain  limits  in  the  City  of  New  York.  Protest 
was  immediately  made  against  the  legality  of  this  regulation  and 
an  action  was  brought  in  the  courts  to  prohibit  the  Metropolitan 
Board  from  carrying  into  effect  its  own  regulations.  This  matter 
was  finally  brought  to  the  Supreme  Court  of  the  State,  which 
upheld  the  regulations  of  the  Metropolitan  Board  of  Health. 
It  would,  therefore,  seem  that  this  was  an  ample  precedent  for 
the  Legislature  to  give  boards  of  health  or  a  public  health  council 
authority  to  enact  regulations  for  the  entire  State  or  any  part 
thereof. 

In  considering  this  feature  of  the  law  it  should  be  remembered 
that  primarily  the  State  was  organized  and  granted  power  by  the 
various  towns  and  cities,  and  that  the  municipalities  had  the  power 
to  enact  sanitary  regulations  for  many  decades  prior  to  the  or- 
ganization of  the  State  government,  and  it  has  been  assumed 
by  some  that  the  State  cannot  take  away  or  supersede  this  power. 
The  courts  have,  as  just  pointed  out,  held  differently  and  altho 
no  test  case  has  been  brought  under  the  present  Sanitary  Code, 
the  Public  Health  Council  and  executiv  officers  of  the  State  De- 
partment of  Health  are  fully  convinced  that  the  regulations  en- 
acted are  constitutional  and  legal. 

About  a  year  ago  the  Board  of  Health  of  the  City  of  New  York 
enacted  a  regulation  forbidding  any  street  car  corporation  in  the 
City  of  New  York  to  admit  to  its  cars  more  persons  that  50 
per  cent,  in  excess  of  the  seating  capacity.  The  railroad  com- 
panies immediately  appealed  to  the  courts  and  the  matter  is  now 
in  abeyance.  The  railroad  companies  also  caused  a  bill  to  be 
introduced  in  the  Legislature  for  the  purpose  of  taking  away  the 
power  of  any  local  board  of  health  in  New  York  State  to  enact 
any  regulations  controlling  the  number  of  persons  to  be  admitted 
in  street  cars  and  this  bill  past  both  houses  of  the  Legislature, 


ISO 

but  as  the  enactment  of  legislation  of  this  kind  was  taking  away 
the  power  and  prerogativ  of  a  board  of  health,  Governor  Whitman 
very  properly  vetoed  this  measure.  This  account  shows  briefly 
the  trend  of  sanitary  legislation.  However,  boards  of  health  and 
public  health  councils  similar  to  the  Public  Health  Council  of 
the  State  of  New  York  should  consider  carefully  each  and  every 
regulation  and  have  good  and  sufficient  sanitary  reasons  for  the 
enactment  of  any  such  regulation.  For,  if  such  boards  or  council 
exceed  their  authority  or  enact  regulations  which  may  cause 
imdue  hardship  upon  an  individual  or  corporation  without  the 
protection  of  public  opinion,  the  power  to  enact  these  regulations 
may  be  taken  away  at  any  session  of  the  Legislature. 

Progress  in  the  enactment  of  new  sanitary  regulations  should 
be  made  deliberately  but  steadily  and  only  along  lines  which  will 
be  definitely  productiv  of  the  greatest  good  in  the  diminution  in 
the  amoimt  of  sickness  and  death.  If  those  in  authority  in  pub- 
lic health  work  have  always  this  end  in  view  they  will  not  fail  to 
steadily  serv  the  people  and  to  conserv  the  public  health,  and  will 
in  the  end  assuredly  receiv  the  support  of  their  respectiv  com- 
munities and  also  of  the  legislativ  bodies. 


INTERSTATE  SANITARY  RELATIONS. 

By  Assistant    Surgeon    General    W.    C.    Rucker,  M.D.,   M.S.,   Gr.P.H.,   United  States 
Public  Health  Service.  Washington,  D.  C. 

The  increase  in  population  and  ease  of  travel  in  the  United 
States  has  vastly  changed  the  sanitary  relations  existing  between 
the  states  since  the  formation  of  our  government.  Originally  a 
sparsely  populated  fringe  of  colonies  bordering  the  Atlantic  Coast, 
having  no  railroads  and  few  highways,  and  depending  for  the 
most  part  upon  slow  sailing  craft,  we  have  become  a  nation  which 
extends  from  ocean  to  ocean,  the  component  parts  of  which  are 
in  intimate  relation  with  one  another  by  swiftly  moving  trains 
and  rapid  steamships.  The  original  isolation  of  the  states  has 
ceased  to  be  and  the  integration  of  our  national  life  has  become 
such  that  insanitary  conditions  in  one  part  of  the  republic  must 
inevitably  exert  an  untoward  effect  upon  almost  the  entire  body 
politic.  As  the  country  has  become  more  thickly  populated 
there  has  occurred  a  pollution  of  the  interstate  streams  which  en- 
dangers the  water  supplies  of  other  states.  The  invention  of 
refrigerator  cars  and  the  introduction  of  intensiv  methods  of 
farming,  particularly  of  truck  gardening,  has  made  it  possible 
for  infection  to  be  rapidly  carried  in  a  viable  state  for  long  dis- 
tances, and  modem  transportation  has  made  equally  possible 
the  rapid  carriage  of  infected  persons  from  state  to  state.  It  is 
thus  seen  that  the  interstate  sanitary  relations  of  the  United 
States  are  exceedingly  complex,  touching  every  stratum  of  life 
and  bearing  upon  the  health  of  every  American  inhabitant. 

The  United  States  has  created  a  first  line  of  defense  against 
disease  from  abroad.  This  has  taken  the  form  of  the  maritime 
and  overland  foreign  quarantine,  and  may  be  called  our  coast 
fortification  against  disease.  So  long  as  we  continue  to  main- 
tain our  foreign  quarantine  on  an  efficient  scientific  basis  we  have 
relatively  little  to  fear  from  the  importation  of  disease  from  other 
countries.  As  witness  of  the  efficiency  of  the  system  may  be 
cited  the  fact  that  no  case  of  yellow  fever  has  occurred  in  the 
United  States  since  1905;  that  despite  the  fact  that  cholera  was 


132 

widespread  in  epidemic  form  in  many  parts  of  Europe  in  1910 
it  gained  no  foothold  in  the  United  States,  and  that  whenever 
plague  has  appeared  in  an  American  seaport  it  has  been  speedily- 
stamped  out  before  it  has  had  an  opportunity  for  further  spread 
As  a  matter  of  fact  it  may  be  stated  that  so  far  as  the  major  pesti- 
lences are  concerned  they  have  practically  ceased  to  exist  so  far 
as  the  interior  of  our  country  is  concerned,  and  that  we  are  now 
free  to  devote  ourselves  to  the  conquest  of  those  commoner  and 
more  familiar  diseases  which  in  their  end  result  are  a  far  greater 
menace  to  our  national  health.  At  the  present  time  measles 
exerts  a  far  more  harmful  influence  on  national  health  than  does 
bubonic  plague,  and  while  there  is  always  a  certain  danger  of  the 
importation  of  typhus  fever  by  lousy  persons  who  evade  quarantine, 
still  our  ability  to  control  this  disease  is  such  that  we  have  little 
to  fear  from  it.  The  great  problem  which  concerns  us  is  the  con- 
trol of  disease  by  the  states  and  the  prevention  of  their  interstate 
spread  by  the  Federal  Government. 

The  constitutional  right  of  the  general  government  to  control 
disease  rests  entirely  upon  the  commerce  clause.  The  police 
powers  of  states  being  reserved  to  the  states,  the  sanitary  policy 
of  our  government  looks  to  the  individual  states  to  control  disease 
within  their  respective  borders  and  to  the  general  government  to 
prevent  the  passage  of  disease  over  the  borders  of  an  infected 
state  into  another  state.  The  line  of  demarcation  between  the 
sanitary  duties  of  the  states  and  those  of  the  general  government 
is  not  and .  cannot  be  sharply  drawn.  If  the  commerce  clause 
may  be  invoked  to  prevent  the  interstate  movement  of  manu- 
factured articles  produced  by  child  labor  within  the  borders  of 
a  sovereign  state,  it  is  seen  that  it  would  be  equally  proper  for  the 
general  government  to  prevent  the  interstate  movement  of  food- 
stuffs manufactured  under  insanitary  conditions  within  the  borders 
of  a  sovereign  state. 

The  complexity  of  this  problem  is  such  that  unless  due  care  is 
observed  there  will  be  an  enormous  overlapping  and  reduplica- 
tion in  the  sanitary  work  of  the  United  States,  and  if  the  general 
government  was  to  go  to  the  extreme  of  its  power  in  the  control 
of  commerce  between  the  states  there  would  be  relatively  little 


133 

need  for  state  departments  of  health.  Carried  still  further  this 
argument  would  abolish  municipal  and  county  health  authorities 
and  place  the  entire  operation  of  health  matters  upon  the  shoulders 
of  the  F'ederal  Government.  This  would  be  a  reductio  ad  absurdam 
entirely  out  of  harmony  with  the  principles  upon  which  our  nation 
is  founded.  It  would,  therefore,  follow  that  in  the  sanitary  re- 
lations between  the  states  there  must  be  a  unity  of  purpose  on 
the  part  of  the  counties,  districts  and  cities  of  every  state  with 
the  state  officials  and  that  all  the  states  must  perform  their  func- 
tions with  uniformity  and  with  due  regard  to  the  union  of  the 
states. 

This  principle  was  gradually  evolved  and  it  was  not  until 
1893  that  it  assumed  a  definite  form.  The  sanitary  history  of 
our  government  shows  a  constant  movement  to  this  end.  In  the 
early  days  of  the  republic  the  states  were  very  jealous  of  their 
own  rights  and  fearful  lest  the  general  government  should  in  any 
way  interfere  with  the  discharge  of  state  functions.  This  was 
soon  seen  to  be  impractical  in  the  administration  of  quarantine 
and  a  definite  attempt  was  made  in  the  third  Congress  to  relinquish 
this  portion  of  the  police  power  to  the  Federal  Government. 
This  failed  and  until  1878  all  quarantine  measures  adopted  by  the 
nation  as  a  whole  were  in  aid  of  state  health  authorities.  Then 
followed  the  period  in  which  states  operated  maritime  quarantines 
according  to  a  minimum  standard  which  was  set  by  the  national 
health  authorities.  In  1893  the  Government  not  only  assumed 
the  right  to  set  the  minimum  standard  of  maritime  quarantine 
but  to  take  charge  of  state  quarantines  and  to  operate  them  once 
they  were  transferred  to  the  authorities  at  Washington.  More 
than  this,  the  act  of  February  15,  1893,  definitely  recognized  the 
Government's  duty  not  only  in  excluding  disease  from  abroad 
but  in  preventing  its  spread  from  state  to  state. 

Under  this  authority  of  law  the  interstate  quarantine  regula- 
tions have  been  promulgated.  For  the  present  these  concern 
themselves  with  the  regulation  of  common  carriers  for  the  pro- 
tection of  the  health  of  passengers,  for  the  safeguarding  of  persons 
living  along  the  right  of  way  and  the  handling  of  the  communicable 
diseases  so  as  to  check  so  far  as  possible  their  interstate  spread. 


134 

These  regulations  indirectly  exert  a  tremendously  beneficial 
effect  upon  national  health.  For  example,  common  carriers 
carrying  passengers  in  interstate  traffic  may  not  furnish  to  passen- 
gers drinking  water  below  a  certain  standard.  The  sources  of 
these  water  supplies  are  certified  semi-annually  and  oftener  under 
certain  circumstances.  As  a  result  many  cities  have  improved 
their  water  supplies  rather  than  have  them  discontinued  for  use 
on  trains  by  Federal  order.  The  abolition  of  the  common  drink- 
ing cup  and  the  common  roller  towel  by  these  regulations  also 
exerts  a  very  salutory  educational  effect  upon  the  public  mind. 
Eventually  the  interstate  quarantine  regulations  will  take  into 
account  the  interstate  shipment  of  milk  and  other  foods  but  as 
yet  the  Government's  health  machinery  is  not  large  enough  to 
attack  this  phase  of  the  problem.  In  the  interstate  sanitary  re- 
lations the  work  which  may  be  carried  on  in  this  way  is  limitless 
and  there  are  many  things  remaining  which  the  national  health 
service  can  and  should  do.  In  the  doing  of  these  things,  however, 
the  policy  should  be  that  of  upbuilding  and  strengthening  the 
^tate  departments  of  health  to  the  greatest  possible  degree. 
They  should  be  encouraged  and  if  necessary  aided  in  the  perform- 
ance of  their  functions  but  the  general  government  should  assume 
none  of  the  duties  which  properly  belong  to  them  and  their  sani- 
tary rights  should  be  scrupulously  observed.  So  far  as  purely 
intrastate  matters  are  concerned  the  governing  principle  should 
be  that  of  sanitary  home  rule  while  in  interstate  relations  and  the 
protection  of  all  the  states  against  the  diseases  of  the  outside  world 
the  Federal  forces  should  be  supreme. 

It  is  not,  however,  practical  for  the  states  to  control  every  situa- 
tion or  to  grapple  with  every  problem  which  arises  within  their 
borders.  Economy  demands  that  the  overhead  expert  machinery 
be  maintained  by  the  states  at  a  standard  suiHicient  for  ordinary 
needs  and  that  in  time  of  great  stress  that  the  general  government 
be  called  upon  for  aid.  The  states  maintain  a  militia  for  the 
preservation  of  peace  within  their  jurisdiction  but  in  time  of  pub- 
lic danger  the  army  is  requisitioned  lest  harm  be  done  to  other 
states.  Similarly  in  time  of  grave  epidemic  the  states  very  properly 
^all  upon  the  Public  Health  Service  for  its  experts  to  speedily 


135 

eradicate  the  disease  before  it  can  spread  to  other  states.  This 
is  an  economy  and  makes  for  efficiency  in  the  protection  of  national 
health. 

In  the  matter  of  research  the  Federal  Government  can  and 
should  render  equal  aid.  To  maintain  forty-eight  corps  of  field 
and  laboratory  workers  would  be  a  needless  expense  when  one  set 
of  Federal  experts  could  perform  the  duty.  What  is  done  for 
one  state  in  this  way  profits  all  the  states  and  a  single  worker  can 
make  similar  investigations  of  conditions  within  each  of  the  states 
one  after  another.  In  the  broader  field  of  research  the  Federal 
Government  very  properly  makes  studies  of  diseases  which  are 
widespread  and  which,  therefore,  affect  the  health  of  many  states. 
The  results  of  this  work  are  available  to  all  the  states.  The  col- 
lection of  morbidity  and  mortality  statistics  primarily  rests  upon 
the  states  but  their  assemblage  into  form  which  fits  them  for  use 
is  the  duty  of  the  general  government.  In  a  similar  way  the 
publication  of  the  results  of  scientific  studies  and  the  work  of 
popularizing  hygiene  and  sanitation  are  functions  which  economy, 
efficiency  and  expediency  dictate  should  devolve  on  the  federal 
health  body.  For  example,  the  Stereopticon  Loan  Library  of 
the  Public  Health  Service  is  able  to  render  excellent  aid  to  health 
lecturers  throughout  the  nation,  while  the  Health  News  reaches 
8500  newspapers  and  millions  of  readers. 

To  sum  up,  there  are  certain  clearly  defined  functions  which 
must  be  discharged  by  state  and  local  health  authorities.  Equally 
there  are  definite  duties  devolving  upon  the  Federal  Govern- 
ment. Between  these  two  there  is  a  zone  in  which  either  may  do 
the  w^ork,  either  separately  or  in  co-operation.  To  accomplish 
this  properly  there  must  be  a  harmony  and  unison  of  purpose 
to  the  end  that  the  health  of  the  nation  may  prosper. 

DISCUSSION. 

Dr.  WiUiam  H.  Price,  Detroit: 

Emfasizing  one  or  two  points  in  the  most  excellent  and  timely  papers,  I 
believe  that  any  enactment  concerning  a  sanitary  code  would  be  better  left 
in  the  hands  of  a  small  legislativ  body.  It  is  my  experience  that  the  enact- 
ment of  instruments  passing  thru  a  large  legislativ  body  is  not  always  most 
satisfactory  in  its  results.     In  Detroit  we  are  fortunate  enuf  to  have  our 


136 

health  authority  vested  in  a  small  board.  Public  health  work  has  become 
more  complicated  and  technical  with  the  progress  of  modern  civilization. 
It  includes  not  only  the  knowledge  of  the  medical  man,  but  that  of  the  engineer, 
the  chemist,  the  bacteriologist,  and  the  worker  in  many  other  specialties. 
Even  after  a  code  of  regulations  has  been  compiled  it  is  of  use  only  as  it  is 
applied  in  a  definit  way,  and  to  accomplish  this  it  is  necessary  to  have  the 
support  of  the  community,  the  support  not  only  of  the  good  citizen  but  of 
the  average  citizen,  that  the  regulations  may  be  operativ  upon  the  minority 
who,  from  opposition,  indifference,  or  an  exaggerated  sense  of  personal  lib- 
erty, is  not  willing  to  be  guided  by  the  judgment  of  the  majority.  As  Emerson 
has  said,  a  law  can  have  only  so  much  force  as  it  has  in  the  character  of  many 
men. 

Dr.  Edward  Jackson,  Denver: 

I  was  much  interested  in  the  paper  of  Dr.  Biggs  concerning  the  possibility 
of  obtaining  an  efficient  state  sanitary  code.  State  laws  have  given  sufficient 
authority  to  local  boards  and  commissions  but  the  possibilities  of  state  legis- 
lation have  generally  been  supposed  to  be  confined  to  the  state  legislature. 
This  view  has  been  a  serious  obstacle  in  obtaining  efficient  state  health  regula- 
tions. This  difficulty  has  been  felt  by  those  administering  the  health  ordi- 
nances in  Denver,  with  reference  to  the  milk  supply.  Denver  has  had  an  ex- 
cellent health  department  for  twenty  years,  and  good  regulations  with  ref- 
erence to  the  milk  supply  but  in  all  that  time  there  has  been  an  obstacle  in  the 
control  of  the  portion  of  the  milk  supply  coming  from  outside  of  the  City. 
The  lack  of  state  requirements  for  the  inspection  of  the  dairies,  cattle,  etc., 
has  interfered  with  the  efficiency  of  the  Denver  regulations.  As  I  understand 
Dr.  Biggs'  paper,  the  work  of  the  legislativ  state  commission  rests,  like  our 
interstate  commerce  regulations,  on  a  comparatively  small  number  of  persons. 
If  such  a  law,  giving  legislativ  authority  within  certain  definit  lines  with 
regard  to  health  matters,  operates  well  and  is  sustained  by  the  courts  of  New 
York,  it  must  have  an  important  influence  in  other  states.  Health  move- 
ments are  held  back  by  conflict  of  authority  between  states  and  local  authori- 
ties, and  between  state  and  national  authority,  and  every  suggestion  we  ob- 
tain for  the  overcoming  of  these  obstacles  is  of  very  great  value.  The  increas- 
ing intercourse  between  communities  raises  this  issue  all  the  time.  We  have 
plenty  of  authority  given  to  many  local  boards,  but  it  is  not  worth  half  as  much 
as  it  would  be  were  it  made  statewide;  and  the  problem  is  all  the  time  passing 
beyond  state  lines.  We  must  depend  upon  a  small  commission  for  efficient 
health  regulations.  It  is  impossible  thru  any  state  legislature  to  get  a  thoroly 
wise  and  effectiv  sanitary  code. 

Dr.  B.  S.  Warren,  Washington: 

The  speaker  just  preceding  me  stated  that  the  interstate  regulations  rested 
upon  a  very  small  peg.  I  don't  think  he  realized  the  authority  of  the  Acts 
of  1890  and  1893.     These  give  the  national  health  authority  power  to  make 


137 

regulations.  The  authority  to  enforce  reasonable  regulations  has  been 
upheld  by  the  United  States  courts  in  the  California  plague  quarantine  de- 
cision. So  far  as  ascertaining  where  the  disease  may  be,  the  Act  of  191 2 
gave  the  United  States  Public  Health  Service  authority  to  investigate  the 
diseases  of  man  without  regard  to  state  lines.  The  broad  powers  given  to  the 
United  States  Public  Health  Service  by  virtue  of  these  three  acts  would  appear 
to  give  ample  authority  for  all  reasonable  regulations  promulgated  by  the 
Service.  The  fact  that  the  Act  of  1893  did  not  have  a  penalty  clause  for 
violation  of  the  Act  does  not  weaken  the  law,  as  it  is  easily  enforcible  by 
the  Department  of  Justice  thru  the  United  States  courts. 

Dr.  Otto  R.  Kichel,  Albany: 

It  occurs  to  me  that  several  important  facts  may  interest  you  in  connec- 
tion with  the  New  York  State  Sanitary  Code  and  its  enforcement,  namely, 
the  statutory  requirement  that  the  Public  Health  Council,  which  enacts  the 
Code,  shall  consist  of  six  members,  three  of  whom  shall  be  physicians  "and 
shall  have  had  training  or  experience  in  sanitary  science,  and  one  shall  be  a  sani- 
tary engineer."  The  law  also  makes  the  Commissioner  of  Health  a  member 
of  the  Council.  Therefore,  of  the  seven  members,  five  must  have  had  train- 
ing or  experience  in  sanitary  science.  The  law  empowers  the  Council  to  pre- 
scribe the  qualifications  of  local  health  officers,  directors  and  sanitary  super- 
visors of  the  state  department,  and  of  public  health  nurses, — and  such  quali- 
fications have  been  prescribed. 

Effort  is  being  made  to  raise  the  standards  and  personnel  of  the  local 
health  officers  upon  whom  depends  very  largely  the  routine  enforcement  of 
the  Code.  In  the  future  candidates  for  appointment  must  be  not  less  than 
twenty-eight  nor  more  than  sixty  years  of  age,  and  shall  have  had  certain 
special  training  or  experience  in  public  health  work.  To  facilitate  this  the 
New  York  University  and  the  University  of  Syracuse  have  prepared  courses 
in  public  health  for  health  officers.  In  order  to  meet  the  prescribed  quali- 
fications many  health  officers  have  enrolled  for  such  instruction. 

The  20,  more  or  less,  sanitary  supervisors,  who  maintain  general  super- 
vision over  the  work  of  the  many  hundreds  of  local  health  officers,  were  ap- 
pointed two  years  ago  from  a  competitiv  civil  service  list.  All  of  the  men 
appointed  had  either  special  training  or  experience  in  sanitary  work,  and 
many  of  them  had  accomplished  some  definit  constructiv  public  health  work. 
The  supervisor  represents  the  State  Health  Commissioner  in  the  field,  and 
each  covers  a  district  which  includes  several  counties,  about  300,000  popula- 
tion, and  about  60  local  health  officers.  He  acts  as  an  advisory  expert  and 
superintendent,  and  is  the  essential  link  between  the  central  state  department 
and  the  local  board.  The  advent  of  the  sanitary  supervisor  has  been  wel- 
comed by  local  authorities  and  already  his  services  have  become  indispensable 
to  them. 

The  work  in  New  York  State  is  progressing  rapidly  and  there  is  a  notice- 
able improvement  in  the  standards  and  efficiency  of  the  local  health  officers. 


138 

In  all  the  larger  municipalities  there  should  soon  be  available  for  these  posi- 
tions men  who  have  had  special  training  or  experience  in  sanitary  science. 
The  result  will  be  constantly  better  enforcement  of  the  sanitary  code  and  other 
Tiealth  regulations  and  a  corresponding  improvement  in  the  public  health 
itself. 

Dr.  George  A.  Hare,  Fresno,  Cal. : 

It  is  interesting  to  note  that  the  Academy  is  developing  a  clearing  house 
for  practical  ideas  in  health  legislation  which  seems  difficult  for  legislators 
to  obtain  in  many  of  our  states.  The  thought  I  gathered  from  Dr.  Biggs' 
paper  is  that  the  Public  Health  Council  of  New  York  has  legislativ  and  exec- 
utiv  power  over  all  the  territory  of  New  York  and  takes  precedence  of  all 
local  health  authorities,  with  the  exception  of  New  York  City.  I  should 
like  to  inquire  why  New  York  City  does  not  come  under  the  same  jurisdiction? 

Dr.  Kichel: 

New  York  City  not  only  has  an  old,  highly  organized,  and  very  efficient 
health  department,  but  its  population  is  much  larger  than  that  of  the  rest 
of  the  State.  It  was  therefore  deemed  entirely  unnecessary  and  imprac- 
ticable to  include  Greater  New  York  in  the  general  state  health  supervision. 

Dr.  Jackson: 

Would  not  the  exception,  made  in  regard  to  New  York  City  not  being 
under  the  jurisdiction  of  the  Public  Health  Council,  form  a  precedent  for 
other  states? 

Dr.  J.  L.  Heffron,  Syracuse: 

I  think  the  situation  is  that  the  Health  Department  of  the  City  of  New 
York  had  been  so  highly  organized  and  had  done  such  splendid  work  that 
Dr.  Biggs  took  the  law  in  force  in  New  York  City  as  a  model  for  the  State 
law.  As  I  understand  it,  the  Council  is  not  only  a  legislativ  but  an  admin- 
istrativ  body. 

Dr.  Eichel: 

In  certain  details  the  Code  enacted  necessarily  corresponded  with  the  New 
York  City  Code,  but  the  New  York  City  Code  was  not  adopted  as  the  State 
code.  It  is  of  interest  to  note  that  a  number  of  municipalities  throughout 
the  State  have  adopted  the  State  Code  almost  in  its  entirety  as  their  local 
regulations,  with  various  additions  to  meet  local  conditions. 

Dr.  Hare: 

I  have  observed  that  if  you  cannot  get  what  you  want,  it  is  well  to  want 
what  you  can  get.  New  York  has  set  an  exceptionally  good  example  in  her 
Public  Health  Council  work  as  outlined  in  this  paper  by  Dr.  Rucker.  I 
think  we  shall  watch  with  more  than  ordinary  interest  the  working  out 
of  this  plan. 


139 

Dr.  Rucker,  closing: 

The  vast  regulatory  powers  which  the  Interstate  Commission  has  all  hang 
upon  the  Commerce  Clause  of  the  Constitution.  Section  3  of  the  Act  of 
February  15,  1893,  provides  that  immediately  after  the  passage  of  the  Act  that 
the  Surgeon-General  shall  examine  into  all  of  the  regulations  of  the  states  for  the 
purpose  of  finding  out  whether  such  regulations  are  adequate  for  the  prevention 
of  the  introduction  of  disease  from  abroad  and  the  prevention  of  disease 
passing  from  one  state  or  territory  to  another  and  that  he  shall  aid  the  local 
and  state  authorities  in  the  enforcement  of  these  regulations.  Should  these 
regulations  be  found  to  be  inadequate  the  Secretary  of  the  Treasury  shall 
promulgate  regulations  for  the  prevention  of  infectious  and  communicable 
disease  from  abroad  and  from  one  state  or  territory  to  another.  If  the  state 
and  local  authorities  are  not  willing  to  enforce  such  regulations  the  President 
shall  take  measures  for  their  enforcement.  There  are  also  penalties  of  fine 
and  imprisonment  for  infraction  of  any  regulations  made  under  any  of  these 
regulations.  There  are  relatively  few  regulations, — only  32.  The  policy 
has  been  to  pass  only  regulations  which  are  reasonable — they  have  to  be  reason- 
able from  the  standpoints  of  sanitation  and  common  sense  to  have  the  force 
of  law.  That  is  the  secret  of  a  good  public  health  law.  No  public  health  law 
is  worth  the  paper  it  is  written  on  unless  the  people  really  want  to  obey  it 
and  really  want  to  see  it  enforced.  As  a  result  there  has  been  very  little 
difficulty  in  getting  the  Interstate  Quarantine  Regulations  obeyed.  As 
time  goes  on  these  regulations  will  be  enlarged  but  only  as  rapidly  as  they  are 
assimilated.  The  Board  which  has  charge  of  the  preparation  of  these  regu- 
lations for  the  Surgeon-General's  signature  and  Secretary  of  the  Treasury's 
signature  goes  on  the  policy  that  it  will  have  nothing  "dead"  in  the  regula- 
tions. In  sanitary  work  you  get  what  you  get  when  you  get  it,  and  you 
don't  get  ideals;  you  just  get  what  you  can  get,  and  you  are  mighty  thankful 
to  get  that.  The  psychology  of  Americans  is  such  that  if  you  try  to  bully 
them  into  doing  a  thing  they  will  turn  right  around  and  go  the  other  way 
as  fast  as  they  can,  but  if  you  explain  a  matter  and  show  them  they  are  getting 
a  square  deal  you  can  get  what  you  are  going  after.  We  have  had  too  much 
sanitary  regulation  in  this  country.  We  have  stuff  on  our  statute  books 
that  is  worse  than  useless,  and  which  would  never  hold  in  court.  Such 
regulation  hurts  the  cause  of  public  health.  The  general  public  in  this  coun- 
try is  nobody's  fool,  and  people  can  tell  when  you  are  trying  to  fool  them. 
If,  on  the  other  hand,  they  know  you  are  telling  them  simply  what  ought  to 
be  done  and  are  asking  for  their  help,  then  health  regulations  will  be  shown 
to  be  worth  while. 


THE  DRINK  PROBLEM  AND  LEGISLATION. 

By  John  Koren,  A.B.,  Boston,  Mass. 

The  differences  of  opinion  about  the  drink  problem  appear  to 
be  irreconcilable.  Many  men  and  more  women  invest  their 
peculiar  doctrine  of  what  should  be  done  to  prevent  the  consump- 
tion of  intoxicants  with  a  religious  significance.  They  have 
elevated  to  a  dogma  the  assumption  that  every  use  of  liquor, 
not  to  mention  its  manufacture  and  sale,  is  sinful.  In  their  eyes 
men  cannot  be  white  sheep,  that  is  morally  solvent  persons, 
unless  they  seek  dry  pastures  for  themselves  and  others.  It  is 
their  creed  that  drink  is  the  chief  source  of  human  ailments, — 
mental  and  physical  diseases,  poverty  and  crime.  These  concep- 
tions bound  their  ideas  of  public  policies  seemingly  to  the  exclu- 
sion of  all  others. 

Opposed  to  this  condition  of  mind — I  cannot  call  it  a  reasoning 
opinion — stand  those  who  hold  that  the  liquor  question  does  not 
present  a  purely  moral  issue  but,  in  its  public  aspects,  one  of  social 
expediency;  and  I  submit  that  this  view  is  compatible  with  as 
deep  a  realization  of  the  ills  that  result  from  the  abuse  of  drink 
and  with  as  abundant  a  desire  to  counteract  it  as  actuate  the 
extreme  reformers. 

I  said  that  the  two  points  of  view  appear  irreconcilable.  At 
bottom  the  reason  for  this  is  that  the  radical  among  our  present- 
day  temperance  reformers  will  not  concede  that  one  may  be 
earnestly  solicitous  about  the  drink  evil  while  denying  the  effi- 
cacy of  their  legal  specific,  and  brand  those  who  differ  with  them 
at  least  as  unconscious  advocates  of  wrong,  if  they  do  not  impute 
to  them  base  motives.  I  refer  to  this  regretfully,  not  because  the 
indiscriminate  hurling  of  anathemas  hurts  much,  but  because 
the  condition  of  mind  back  of  it  presents  one  of  the  greatest 
obstacles  to  progressive  temperance  reform. 

To  make  this  statement  is  to  express  the  belief  that  the  drink 
evil  cannot  be  cured  by  sumptuary  legislation.  My  reason  for 
this  conviction  can  be  stated  simply,  and  I  trust  without  the 
acrimony  of  one  who  desires  to  provoke  controversy. 


141 

The  theory  of  prohibition  rests  upon  a  false  psychology.  It 
assumes  that  private  habits  and  modes  of  life  are  amenable  to 
legislative  control  in  matters  that  do  not  involve  a  distinction 
between  absolute  right  and  wrong  but  merely  what  is  socially 
desirable.  The  theory  overlooks  the  fundamental  question 
Why  do  men  drink?  ignoring  the  fact  that  the  world-wide  use  of 
intoxicants  denotes  a  demand — we  can  condemn  it  as  much  as 
we  please — which  will  seek  its  usual  satisfaction  unless  we  suc- 
ceed in  stilling  it  through  some  substitute  or  direct  it  into  safer 
channels.  The  prohibition  theory  further  assumes  that  the  only 
thing  needful  to  make  it  effective  is  its  approval  by  a  bare  ma- 
jority of  voters,  whether  obtained  by  persuasion  or  by  downright 
coercion.  The  almost  platitudinous  maxims  that  a  strong 
minority  opposition  undermines  sumptuary  laws,  and  that  no 
legislation  can  accomplish  its  task  unless  it  is  re-enforced  by  a 
strong  public  opinion,  are  brushed  away  as  if  they  had  lost  their 
meaning.  The  prohibition  theory  assumes  that  the  verdict 
given  in  its  favor  is  unalterable,  and  therefore  men  seek  to  write 
it  into  the  organic  law  of  the  country.  How  unstable  the  majori- 
ties are  in  their  attitude  toward  liquor  legislation,  history  has 
abundantly  recorded.  Finally,  the  main  reliance  of  prohibition 
in  order  to  become  effective  is  not  popular  conviction  but  force — • 
police  force — and  thereby  hangs  the  long  and  painful  story  of  its 
failures. 

The  prohibition  attitude  involves  a  curious  contradiction: 
The  liquor  question  is  proclaimed  to  be  a  moral  issue  and  in  the 
same  breath  right  of  option  is  insisted  upon.  But  do  we  ever 
submit  other  questions  which  mankind  agree  relate  to  an  in- 
herent wrong  for  a  decision  at  the  polls?  By  the  very  appeal 
to  a  plebiscite  it  is  confessed  that  the  issue  is  one  of  social  expe- 
diency and  not  one  of  abstract  morals. 

The  vicissitudes  that  mark  the  attempt  to  enforce  prohibition 
I  shall  pass  over  except  to  say  that  we  can  take  but  scant  com- 
fort in  the  successes  with  which  we  are  regaled.  Or  is  the  legal 
disappearance  of  that  embodiment  of  the  drink  evil,  the  saloon, 
an  especial  cause  for  rejoicing  so  long  as  it  is  not  synonomous 
with  a  cessation  of  the  abuse  of  drink?    Let  me  point  out  but  a 


142 

single  disquieting  fact:  while  there  is  boast  that  never  before  in 
the  history  of  this  country  so  large  territory  has  been  laid  dry, 
the  revenue  returns  according  to  reports  indicate  an  increase  of 
about  ten  million  gallons  in  spirits  withdrawn  for  consumption 
during  the  current  fiscal  year  and  the  sixty  million  gallons  de- 
crease in  the  production  of  beer  does  not  offset  it,  but  is  from 
the  temperance  point  of  view  merely  a  matter  for  regret. 

Furthermore,  I  beg  you  to  remember  that  unenforced  prohi- 
bition has  its  attendant  evils  which  may  far  outweigh  an  apparent 
gain  in  sobriety.  The  habitual  and  open  violation  of  the  law 
at  which  so-called  good  men  connive  breeds  contempt  for  law  in 
general,  sows  corruption,  and  corrodes  the  public  conscience. 

It  is  a  saddening  spectacle  of  public  morality  when  in  a  prohibi- 
tion locality  all  political  activities  pivot  upon  the  question  whether 
the  constitutional  and  statutory  law  relating  to  drink  shall  be  up- 
held. 

It  will  be  answered  that  the  entire  fabric  of  arguments  will 
tumble  about  my  ears  on  the  advent  of  prohibition  of  the  national 
variety.  To  which  the  only  answer  is:  the  assumption  rests 
upon  the  same  false  psychology;  the  same  blind  reliance  upon  the 
validity  of  artificial  majorities;  the  same  doctrine  that  morality 
is  gained  by  coercion;  the  same  appeal  to  brute  force  as  a  means 
for  making  a  man  sober.  Why  this  confusion  of  thought  and  of 
relative  values?  The  nation  appears  to  make  preparedness  its 
slogan.  Apparently  it  occurs  to  but  a  few  that  one  essential  is 
to  be  prepared  in  mind,  and  I  solemnly  assert  that  one  unmis- 
takeable  indication  of  our  intellectual  unpreparedness  is  the 
fatuous  manner  in  which  we  are  content  to  seek  a  solution  of  the 
liquor  problem. 

This  blunt  utterance  of  what  to  me  seems  to  be  incontrovertible 
truths  wiU  in  some  quarters  earn  for  me  added  reputation  as  an 
enemy  of  temperance  reform.  But  does  the  condemnation  of 
theoretical  vagaries  and  their  failures  when  translated  into  prac- 
tice involve  any  criticism  whatsoever  of  the  essence  of  temperance 
reform?  I  should  be  the  last  to  deny  that  the  vast  activities  to 
stem  the  traffic  in  liquor  have  been  without  lasting  wholesome  re- 
sults.    One  can  indulge  in  the  most  wholesome  denunciation  of 


143 

the  excesses  of  the  trade,  its  lust  for  socially  dangerous  power, 
its  greed  of  money  which  makes  it  batten  upon  other  men's  mis- 
fortune; one  can  roundly  denounce  the  iniquities  of  the  saloon 
and  advocate  its  banishment  in  many  ways;  one  can  preach  the 
virtues  of  sobriety,  and  yet  insist  earnestly  and  truthfully,  that 
our  theories  of  liquor  legislation,  whether  they  relate  merely  to 
the  control  of  the  traffic  or  to  its  abolition,  each  in  its  own  way 
spells  rnore  or  less  evident  failure. 

No  one  will  venture  to  dispute  that  rational  social  legislation 
must  be  based  upon  truthful  concepts  of  the  problem  it  deals  with, 
and  that  we  must  legislate  stupidly  and  in  vain  if  we  let  our  vision 
be  obscured  by  false  and  exaggerated  notions.  The  motive  in 
liquor  legislation  does  not  divide  us;  it  is  to  prevent  intemperance. 
Surely  there  is  no  need  of  enlarging  upon  the  evils  that  flow 
from  the  abuse  of  drink — they  are  too  palpable  and  saddening. 
Science  has  powerfully  come  to  the  support  of  temperance  effort 
by  re-enforcing  what  already  common  sense  teaches  about  the 
dangers  of  alcoholic  indulgence.  But  science  has  not  yet  demon- 
strated that  every  use  of  intoxicants  is  necessarily  injurious  and 
until  that  time,  if  it  comes,  or  until  the  great  mass  of  individuals 
is  permeated  by  the  conviction  that  their  personal  use  is  harmful 
and  wrong,  legislation  which  would  far  outstrip  public  opinion 
merely  writes  its  own  doom. 

Does  not,  therefore,  wisdom  lie  in  legislation  designed  to  pre- 
vent abuse  and  gradually  to  diminish  consumption  rather  than 
to  attempt  the  impossible — to  stop  all  use?  The  promise  of  a 
heyday  of  virtue  and  prosperity  and  the  absence  of  the  great 
human  ailments  under  sumptuary  legislation  is  but  pleasant 
moonshine  without  warmth  and  without  substance.  Drink  has, 
indeed,  the  gravest  consequences  to  answer  for,  but  total  abstinence 
is  not  a  primary  virtue,  and  in  the  nature  of  things  does  not 
suffice  to  abolish  disease,  poverty,  vice  and  crime.  Therefore 
do  not  let  us  premise  our  laws  on  the  untenable.  Our  constant 
abortive  efforts  in  legislation  arise  in  large  part  from  the  fact 
that  we  either  attempt  this  or  are  content  with  legislative  measures 
which  ignore  common-sense  principles  of  progressive  control. 

Having  thus  given  the  briefest  possible  accoimt  of  my  point 


144 

of  view,  let  me  try  to  summarize  some  constructive  efforts  that 
hav^  not  yet  been  attempted  but  which  are  elsewhere  accepted 
as  stepping  stones  toward  an  increasingly  effective  repression  of 
the  drink  evil. 

Our  laws  commit  the  unpardonable  blunder  of  treating  all 
intoxicating  liquors  alike  from  the  point  of  view  of  taxation. 
We  make  them  bear  the  heaviest  possible  burden  without  asking 
whether  this  method  is  in  the  interest  of  temperance.  It  does 
not  require  demonstration,  least  of  all  before  the  present  assem- 
bly, that  the  real  scourge  of  the  drink  evil  is  to  be  found  in  the 
abuse  of  distilled  liquors.  Yet  we  do  not  discriminate  by  aid  of 
differential  taxation  in  favor  of  the  least  alcoholic  and  therefore 
least  injurious  beverages.  Indeed,  legislation  goes  to  the  absurd 
extreme,  in  some  instances,  for  forbidding  within  so-called  dry- 
territory  the  use  of  any  liquor  bearing  the  terrifying  name  of 
malt,  whether  it  be  intoxicating  or  not!  By  the  same  token, 
where  the  sale  of  beers  is  legalized  no  distinction  is  made  between 
the  heaviest  and  intoxicating  kinds  and  those  that  by  scientists 
as  well  as  by  prohibitionists  in  more  enlightened  countries,  are 
regarded  and  treated  in  law  as  non-intoxicating,  that  is,  generally 
speaking,  all  beers  under  2V4  per  cent,  alcohol.  H^re,  then,  is  a 
fruitful  field  for  reform  which  should  have  for  its  object  nothing 
less  than  the  virtual  extinction  of  the  manufactture  and  sale  of 
spirits,  and  the  substitution  of  fermented  kinds,  favoring  the  least 
intoxicating.  Perhaps  in  time  we  shall  be  ready  to  take  another 
step  in  advance. 

Otu"  present-day  license  systems  virtually  put  a  premium  on 
the  distilled  liquors  by  subjecting  them  to  the  same  regulations 
and  the  same  burdens  as  the  fermented  kinds  which  do  infinitely 
less  harm.  Indeed,  we  legislate  in  license  matters  as  if  the  en- 
tire object  were  to  obtain  as  great  returns  as  the  traffic  will  bear 
without  questioning  if  we  thereby  counteract  abuses  and  pre- 
vent intemperance. 

Time  will  not  permit  me  to  discuss  the  merits  and  demerits 
of  present  systems  of  issuing  and  controlling  liquor  licenses. 
For  the  most  part,  they  set  a  poor  example  of  effectiveness. 
For  the  same  reason  I  cannot  dwell  on  the  hundred  and  one 


( 


145 

« 

restrictive  devices  whose  ostensible  purpose  it  is  to  lessen  abuse 
in  some  way.  A  few  of  them  are  obviously  beneficial,  many  are 
futile,  and  some  purely  irritating. 

Let  us  rather  turn  to  a  possible  substitution  for  licensing 
systems  which,  under  proper  modifications  and  safeguards  of  the 
law,  can  surely  be  adapted  to  American  needs  on  a  large  scale. 
I  refer  to  the  so-called  Company  System  of  Scandinavian  origin. 
Its  essence  is  that  instead  of  granting  privileges  to  sell  intoxicants 
to  private  individuals,  they  may  be  given  for  a  whole  community 
which  declares  itself  in  favor  of  license  to  a  private  company 
which  engages  in  the  traffic  without  prospect  of  other  benefits 
than  a  modest  return  on  the  capital  invested  and  thus  is  shorn 
of  the  incentive  to  push  the  sale  of  liquor  for  private  profit. 
The  system  at  once  divorces  the  sale  of  liquor  from  any  affiliation 
with  politics,  excludes  private  interests,  and  sets  itself  the  one 
object  of  restricting  consumption  and  divesting  it,  so  far  as  possi- 
ble, from  harm,  by  a  number  of  devices  which  lie  easily  to  hand, 
such  as  limiting  the  hours  of  sale,  the  quantity  that  can  be  pur- 
chased, and  blacklisting  habitual  inebriates.  Only  one  objec- 
tion can  be  raised  to  experimentation  with  this  system,  which  in 
the  course  of  many  years  of  trial  has  abundantly  proved  its  worth, 
— the  one  coming  from  the  extreme  temperance  wing  which  be- 
lieves that  any  sale  of  intoxicants,  no  matter  under  what  auspices 
and  how  unproductive  of  actual  intemperance,  is  inherently 
wrong  and  therefore  cannot  be  permitted. 

Let  me  not  be  misundestood  at  this  point.  I  believe  that  the 
local  community  should  exercise  the  privilege  of  determining  for 
itself  whether  or  not  it  will  tolerate  the  traffic  in  intoxicants. 
Local  option  is  a  principle  which  has  come  to  stay.  But  I  see  its 
shortcomings  when,  for  instance,  the  attempt  is  made  to  lay  an 
urban  community  dry  against  its  will  by  the  aid  of  the  rural 
vote,  or  when  a  handful  of  voters  on  petition  can  at  an  opportune 
time  force  a  vote  favorable  to  their  side.  In  short,  we  boast 
of  the  invention  of  the  principle  of  local  option  but  fall  pitifully 
short  in  its  application  and  tolerate  its  perversion  not  in  the  in- 
terests primarily  of  temperance  but  in  the  interests  of  statewide 
prohibition. 


146 

It  is  right  that  the  local  community  should  outlaw  the  saloon 
if  it  seems  expedient  to  do  so.  The  country  at  large  shows  little 
tolerance  with  the  saloon  as  an  institution.  And  there  is  common 
consent  that  it  no  longer  has  a  place  in  the  village  or  in  the  coun- 
tryside. For  this  let  us  be  thankful.  But  where  a  community 
shows  no  inclination  to  abide  by  the  verdict  that  there  shall  be 
no  more  saloons  or  where  their  exclusion  simply  means  that  the 
illegal  traffic  with  all  horrors  flourishes,  then  such  a  community 
should  be  given  the  chance  by  means  of  the  Company  System 
to  provide  a  substitute  which  safeguards  the  sale  of  intoxicants 
so  far  as  human  ingenuity  and  conscientious  endeavor  will 
permit. 

In  the  present  state  of  public  feeling  and  thinking  about  the 
liquor  problem,  in  view  of  the  composition  of  the  populations, 
I  solemnly  believe  that  in  urban  communities  of  any  magnitude, 
particularly  where  they  are  isolated  from  the  larger  centers, 
evil  and  not  good  will  come  from  an  attempt  to  gain  abstinence 
from  drink  through  coercion.  But  this  does  not  mean  that  the 
medium  through  which  drink  is  dispensed  should  be  permitted 
to  remain  the  same,  much  less  the  excesses  which  we  legislate 
against  and  deplore.  Some  will  deny  vehemently  that  the  sug- 
gestions I  have  offered  would  progressively  promote  temperance. 
The  difference  between  us  lies  in  this, — I  would  take  some  ac- 
count, if  you  please,  of  the  frailties  of  human  nature,  I  would  ap- 
proach gradually  the  goal  that  all  desire  and  mean  to  work  for, 
believing  to  see  clearly  and  without  a  shadow  of  doubt  that  human 
progress  does  not  come  in  obedience  to  a  legislative  mandate 
but  by  persuasion  and  education,  and  is  merely  aided  by  laws 
which  rest  upon  the  firm  foundation  of  public  conviction  about 
what  is  expedient  and  right.  He  must  be  blind  indeed  who  does 
not  see  that  in  obedience  to  the  very  things  I  have  mentioned 
there  has  been  steady  advance  toward  sobriety  and  cleaner  living. 
To  deny  this  is  to  condemn  the  most  patent  forces  in  human  life. 
What  further  progress  shall  be  made  depends  in  no  small  measure 
on  wise  laws,  but  let  us  not  commit  the  fatal  mistake  of  assuming 
that  sobriety  and  other  virtues  that  should  adorn  our  civilization 
will  spring  into  life  by  the  mere  fiat  of  legislation. 


147 

Dr.  William  R.  White,  Providence: 

Mr.  Chairman:  I  have  been  intensely  interested  in  the  paper  to  which  we 
have  just  listened.  I  wish  the  reader  would  give  us  a  little  more  in  detail  the 
working  application  of  what  I  think  he  termed  the  Company  System  of 
control  originated  in  Scandinavia,  whether  it  embraces  the  wholesale  and 
retail  distribution  of  intoxicants  and  what  are  the  actual  results  of  its  opera- 
tion. I  must  say  that  I  am  in  sympathy  with  his  argument  against  the 
sumptuary  attempt  at  controlling  the  use  of  all  intoxicants.  I  live  in  a  city 
where  both  license  and  prohibition  have  been  tried.  I  remember  well  what 
rejoicing  existed  in  the  community  among  the  advocates  of  prohibition 
when  that  law  was  enacted.  This  enactment  resulted  largely  from  the  in- 
coming of  strangers  who  talkt  most  forcibly  in  favor  of  prohibition.  The 
law  remained  in  force  for  two  years  and  then  an  overwhelming  vote  restored 
the  license  law.  I  do  not  wish  to  speak  on  the  merits  of  the  two;  I  am  not 
competent  to  discuss  them  adequately,  but  I  know  that  our  community  was 
very  much  dissatisfied  with  the  working  out  of  the  so-called  statutory  pro- 
hibition. It  resulted,  as  it  has  many  times,  in  the  back  door  and  basement 
sale  of  abominably  poor  liquors.  It  did  not  stop  intoxication;  it  did  not  stop 
crime;  it  did  not  stop  inebriety  among  our  working  classes.  It  led  to  a 
condition  that  was  entirely  unsatisfactory.  I  am  very  much  interested  in  the 
constructiv  argument  of  the  speaker. 

Mrs.  Florence  Kelley,  New  York  City: 

I  spend  my  summers  in  Maine,  a  State  which  has  given  a  longer  trial  to 
prohibition  than  Rhode  Island  has  done.  Every  one  here  remembers  no 
doubt  that  a  few  years  ago  the  State  of  Maine,  after  trying  state-wide  pro- 
hibition for  fifty  years,  submitted  to  a  referendum  the  question  whether 
prohibition  should  be  continued  as  a  part  of  the  Constitution.  By  a  very- 
small  majority  Maine  retained  state-wide  prohibition.  Three  grave  diffi- 
culties were  mentioned  in  the  campain:  That  it  could  always  be  shown 
that  there  was  a  great  deal  of  drunkenness  in  Maine,  This  was  beHeved  by 
the  people  of  Maine  to  be  the  result  of  other  states  sending  into  Maine,  in 
defiance  of  the  laws  of  Maine,  large  quantities  of  alcoholic  drinks  of  all  kinds, 
particularly  heavily  laden  distilled  liquors.  These  were  brought  in  under  the 
Federal  provision  covering  unbroken  packages.  Another  difficulty  was  the 
immigration  of  people  accustomed  to  drinking  distilled  liquors  with  heavy 
proportions  of  alcohol,  who  availed  themselves  of  the  Federal  law.  The 
third  difficulty  was  that  those  people  within  the  State  of  Maine  who  suffer 
most  from  the  abuse  of  liquor  and  have  the  least  enjoyment  in  drinking — 
the  women  of  Maine — have  no  share  in  deciding  whether  there  shall  be  local 
enforcement  of  the  State  law. 

In  discussing  the  results  of  sumptuary  legislation  it  is  well  to  keep  in  mind 
the  limited  power  of  any  state  to  establish  it,  under  the  present  Federal 
legislation  and  judicial  decisions,  and  the  lack  of  voting  power  of  the  people 


148 

who  suffer  most  from  the  evils  of  drunkemiess.  It  seems  fairer  to  consider 
as  a  basis  of  discussion  a  state  in  which  prohibition  has  been  tried  out  half 
a  century  and  in  which,  with  all  its  limitations,  it  is  thought  worthy  of  con- 
tinuance, rather  than  to  dismiss  as  a  failure  a  state  prohibition  law  which 
has  been  tested  for  two  years,  and  then  generalize  from  that  failure. 

Dr.  Tom  A.  Williams,  Washington,  D.  C: 

I  cannot  speak  upon  this  matter  from  any  experience  with  legislation,  nor 
can  I  speak  of  personal  knowledge  of  any  prohibition  state;  but  the  remarks 
of  the  last  two  speakers  make  me  wish  to  come  forward  and  say  something 
about  certain  prohibition  states  which  I  happen  to  know  about  very  well 
second-hand,  that  is  to  say,  from  statements  made  to  me  by  professional 
colleagues  practicing  in  those  states  who  had  good  opportunity  to  observ 
the  situation,  because  they  were  men  of  practical  minds  and  of  the  better 
type.  I  am  referring  to  men  whom  I  see  in  medical  consultations  in  those 
states.  The  States  particularly  referred  to  are  West  Virginia  and  North 
Carolina.  In  Virginia  only  recently  prohibition  has  been  enacted  and  it 
would  not  be  fair  to  say  anything  about  the  state  of  opinion  there.  Physi- 
cians to  whom  I  have  spoken  living  in  West  Virginia  nearly  all  believe  that 
the  prohibition  law  in  that  State  has  greatly  lessened  crime,  has  increast 
the  prosperity  of  their  communities  and  has  met  with  scarcely  any  dissatisfac- 
tion. Apparently  the  law  has  been  as  successfully  carried  out  as  one  could 
expect  where  the  drawbacks  spoken  of  by  the  last  speaker  exist  to  some 
extent.  It  must  be  remembered,  however,  that  these  States  are  inhabited 
by  people  who  in  very  large  proportion  (  I  refer  to  the  negroes)  are  not  re- 
garded as  worthy  of  the  full  possession  of  political  rights  and  that  the  pro- 
hibition measure  is  lookt  upon  as  one  of  protection  for  them. 

I  was  very  much  interested  to  read  in  the  paper  the  other  day  Mr.  Gar- 
field's remark  in  reply  to  the  attempt  to  introduce  into  the  Progressive 
Party's  platform  the  prohibition  provision.  He  said  that  he  thought  the 
matter  was  one  rather  of  education  than  of  prohibition.  That  might  be 
interpreted  to  mean  education  to  tolerate  prohibition,  just  as  one  is  educated 
to  tolerate  certain  discipline  in  civil  life,  which  is  unpleasant  perhaps  to  us 
when  we  are  young  men,  which  we  accept  on  account  of  its  value.  Theoreti- 
cally, of  course,  in  a  democratic  country,  the  position  of  the  prohibitionists 
is  entirely  untenable.  It  assumes  a  certain  interference  with  liberty  to  do  as 
one  pleases  about  his  own  particular  habits.  Practically  speaking,  I  have 
come  to  think  that  perhaps  it  is  a  wise  expediency  until  we  can  attain  to 
educational  standards  of  information  regarding  our  bodies  and  our  minds 
which  will  make  us  all  see  that  alcohol  is  a  rather  unnecessary  and  often  a 
very  unwise  indulgence.  We  have  to  remember,  however,  that  even  in  a 
democracy  and  when  that  democracy  is  educated,  as  I  hope  it  will  be,  there 
are  certain  individuals  who  on  account  of  their  own  particular  weakness, 
often  psychological,  have  particular  temptations  to  the  kind  of  stimulation 
which  is  produced  by  alcohol.     Until  we  take  more  care  to  provide  for  the 


149 

special — education,  I  should  call  it,  but  it  means  more  than  the  ordinary 
education  of  such  individuals — ^we  shall  always  have  many  people  who  have 
a  strong  craving  for  some  kind  of  what  has  been  called  stimulant,  tho  alcohol 
is  probably  not  a  stimulant.  The  problem  will  never  be  solved  until  we  take 
account  of  those  individuals  who  are  the  exception,  yet  quite  numerous 
and  often  of  high  usefulness  to  the  community. 

Dr.  L.  Duncan  Bulkley,  New  York  City: 

I  think  the  statement  of  Mr.  Koren  that  the  medical  profession  is  not 
united  upon  the  harmfulness  of  alcohol  should  not  go  unchallenged.  Ten 
or  fifteen  years  ago  in  London  Sir  Victor  Horsley,  in  speaking  upon  alcohol, 
exhibited  a  diagram  showing  the  steadily  lessened  quantities  of  alcohol  used 
in  the  hospitals  in  the  last  ten  years.  He  also  had  taken  from  the  books  the 
amount  of  money  spent  on  milk  each  year  in  the  same  ten  years,  and  the 
amounts  were  practically  reversed.  The  results  showed  that  alcohol  had 
been  excluded  from  medical  use,  which  is  certainly  the  experience  and  view 
of  the  best  physicians  now. 

Dr.  F.  F.  Lawrence,  Columbus: 

Does  this  report  give  any  figiures  to  show  how  much  of  the  alcohol  was 
given  to  the  patients  and  how  much  was  consumed  by  the  staff? 

Dr.  Bulkley,  New  York  City: 

I  am  positiv  that  were  some  such  diagram  made  from  our  New  York 
hospitals  that  the  result  found  in  the  London  hospitals  would  be  duplicated 
in  almost  every  instance. 

Mr.  Koren: 

My  statement  was  that  the  medical  profession  was  not  entirely  agreed  that 
alcohol  under  all  conditions  and  under  all  circumstances  was  injurious.  That 
has  nothing  to  do  with  its  consumption  in  hospitals. 

Dr.  Bulkley: 

I  think  the  profession  is  practically  agreed  upon  eliminating  alcohol  from 
the  practice  of  medicine.  I  merely  felt  that  the  statement  of  Mr.  Koren 
ishould  not  go  unchallenged  in  a  medical  body,  when  it  is  so  well  known  that 
alcohol  is  so  much  less  used  than  formerly. 

Dr.  Lawrence: 

I  want  to  call  attention  to  one  thing  only,  the  constructiv  side  of  legislation, 
not  only  concerning  alcohol,  but  regarding  the  question  of  health  insurance, 
for  instance.  Such  insurance  is  coming  just  as  surely  as  that  the  sun  rises 
in  the  East,  and  it  behooves  the  medical  profession  and  particularly  the 
American  Academy  of  Medicine,  to  get  busy  and  very  busy  in  a  constructiv 
work,  and  see  that  health  insurance  is  made  impossible  in  every  state  for  the 
users  of  alcohol  to  excess,  and  that  physicians  who  use  alcohol  at  all  cannot 
be  examiners  for  health  insurance.  That  is  a  constructiv  proposition  for 
consideration. 


I50 

Dr.  Edward  Jackson,  Denver: 

It  may  be  that,  in  the  matter  of  temperance  as  in  the  matter  of  sanitary 
codes,  "We  get  what  we  get  when  we  get  it."  While  the  theory  of  sumptuary 
legislation  may  be  very  defectiv,  there  is  a  practical  psychology  underlying 
the  movements  toward  what  is  called  prohibitory  legislation.  In  prohibition 
legislation  there  are  going  on  many  slightly  different  kinds  of  legislativ  ex- 
periments, and  a  close  examination  of  all  these  experiments  may  teach  some 
important  facts.  In  Colorado  there  was  added  a  prohibition  amendment 
to  the  State  Constitution,  which  went  into  effect  the  first  of  January  of  this 
year.  It  was  a  movement  that  seemed  to  me  at  the  time  of  doubtful  wisdom, 
tho  I  was  not  prepared  to  oppose  it  and  I  watcht  the  operation  with  a  good 
deal  of  interest.  In  the  first  place,  the  law  is  prohibitory  only  in  a  certain 
sense;  under  existing  conditions  outside  of  the  State  any  one  in  Colorado 
who  has  sufficient  foresight  and  self-control  can  get  all  the  liquor  he  wants  to 
use.  There  are  certain  restrictions  on  the  shipment  of  liquor  into  the  State. 
It  has  to  be  consigned  to  the  person  who  is  to  be  the  consumer  and  it  has  to 
be  labeled.  Certain  records  have  to  be  kept  of  the  consignment  but  no  one 
in  Colorado  is  prevented  from  getting  all  that  he  needs  of  any  kind  he  chooses, 
under  certain  restrictions.  The  enactment  has  stopt  the  manufacture  of 
malt  liquors  and  of  all  distilled  liquors  within  the  State.  It  has  stopt  ab- 
solutely the  saloon,  as  the  saloon  was  known  previously  and  as  the  saloon  is 
known  in  most  parts  of  the  country,  and  apparently  it  is  going  to  be  per- 
manently effectual  in  that  direction.  It  has  not  stopt  the  use  of  beverages 
that  contain  less  than  2  per  cent,  of  alcohol.  At  least  two  of  the  breweries 
in  Denver  have  gone  into  the  manufacture  of  "Near-beer,"  and  other  pro- 
prietary beverages  that  contain  alcohol  in  less  than  2  per  cent.  These 
beverages  are  largely  used  by  the  former  drinkers  of  beer.  This  prohibitory 
legislation  has  caused  the  consumption  of  beverages  with  a  very  low  alcohol 
percentage  instead  of  beverages  with  a  much  higher  alcoholic  percentage. 
There  is  no  doubt  that  in  Denver,  which  is  perhaps  the  largest  city  in  the 
country  which  has  adopted  prohibitory  legislation,  having  250,000  inhabi- 
tants, it  has  caused  very  much  less  drunkenness,  altho  the  majority  of  voters 
in  Denver,  including  the  women,  were  against  the  prohibitory  amendment. 
There  was  a  majority  of  between  8,000  and  10,000  against  the  amendment 
in  Denver  and  only  10,000  for  it  in  the  whole  State.  Only  within  a  week 
I  noticed  in  the  daily  papers  the  serious  proposition  is  coming  up  before  the 
councils  of  the  city  to  provide  a  substitute  for  the  supply  of  broken  stone 
that  had  come  from  the  "rock  pile"  to  which  the  drunks  were  sent.  Since 
the  first  of  January  no  men  have  been  sentenced  to  breaking  stone  for  drunken- 
ness and  the  supply  of  broken  stone  has  run  out.  The  effect  of  this  legislation 
is  undoubtedly  different  from  that  of  other  prohibitory  legislation  in  other 
states.  This  legislation  is  largely  experimental  and  is  worth  looking  at  in  the 
scientific  spirit,  endeavoring  to  recognize  the  resemblances  and  differences  of 
effect  in  different  localities  and  under  slightly  different  enactments. 


151 

Dr.  A.  J.  Read,  Battle  Creek,  Mich.: 

I  feel  that  a  paper  of  this  type  ought  to  call  forth  considerable  discussion 
from  the  Academy  of  Medicine.  I  do  not  think  that  we  could  accept  in 
toto  all  the  ideas  advanced  by  the  author  of  the  paper  and  I  do  not  believe 
that  he  would  expect  us  to.  The  paper  has  presented  to  us  a  constructiv  idea 
in  legislation  and  controlling  the  drink  problem,  which  is  worthy  of  some 
study  and  consideration,  I  beheve,  the  constructiv  idea,  as  I  understand  it, 
being  a  substitute  for  the  present  prohibitory  measures  more  or  less  in  vogue 
thruout  the  country  in  a  sort  of  restrictiv  legislation  controlling  the  sale  of 
intoxicants  and  as  a  substitute  for  so-called  sumptuary  legislation. 

Mr.  Koren  (to  Dr.  Read) : 

If  you  understand  my  constructiv  idea  clearly — it  is  a  direct  step — when 
public  conviction  is  ready  for  it — toward  any  sort  of  prohibition. 

Dr.   Read   (continuing): 

The  constructiv  program,  it  seems  to  me,  does  call  for  more  or  less  false 
premise  as  presented  by  the  paper.  The  author  of  the  paper,  as  I  under- 
stand it,  takes  for  granted  that  the  present  prohibition  movements  more  or 
less  prevalent  in  the  country  have  been  executed  more  from  a  moral  basis 
than  from  a  scientific  basis.  I  would  feel  like  challenging  that  on  the  basis 
of  fact  as  I  understand  the  question.  I  do  not  think  that  the  legislation 
which  the  intelligent  men  of  this  country  have  enacted  prohibiting  the  sale  of 
intoxicants  has  been  on  a  moral  basis.  I  will  admit  that  there  are  moral 
problems  involved,  and  that  they  have  been  felt  very  often  in  the  agitation 
of  the  subject,  but  I  do  not  think  the  legislation  has  been  purely  on  a  moral 
basis.  The  question  of  personal  liberty  is  involved;  but  I  do  not  know  of 
such  a  single  law  that  does  not  curtail  personal  liberty.  I  need  only  mention 
Emma  Goldman  and  other  speakers  of  that  type.  My  understanding  of  my 
right  to  life,  liberty  and  the  pursuit  of  happiness  is  that  whenever  the  habits 
or  acts  of  another  interfere  with  that  right,  it  is  time  that  legislation  should 
control  them.  Here  in  Detroit  a  short  time  ago  a  company  of  joy-riders  at 
one  o'clock  at  night  ran  into  a  street  car,  smashing  into  it  in  terrible  shape — 
suppose  you  had  been  in  the  automobile.  We  have  come  to  a  day  when  the 
lives  of  men  hang  in  the  balance  of  other  men's  actions,  and  for  that  reason 
I  believe  it  is  perfectly  proper  that  men  should  be  prevented  by  legislation 
from  using  intoxicants.  I  do  not  believe  that  prohibition  as  it  has  been 
enacted  thruout  the  United  States  does  materially  interfere  with  the  personal 
liberty  of  any  man  or  set  of  men  as  long  as  they  honestly  want  to  carry  on 
honest,  straightforward  business  tending  to  the  general  uplift.  So  it  seems 
to  me  that  there  is  a  bit  of  sofistry  in  this  paper  and  I  should  like  to  have  the 
whole  subject  well  studied  before  its  acceptance  by  a  body  of  scientific  men. 

The  President,  Dr.  George  A.  Hare,  Fresno,  Cal. : 
I  wish  to  thank  the  reader  of  the  paper  for  presenting  this  subject.    Whether 


152 

or  not  we  endorse  the  thought  of  the  author,  the  paper  has  led  to  a  considera- 
tion of  a  problem  which  is  being  discust  pro  and  con  and  which  will  be  settled 
finally  by  intelligent  legislation  just  as  inevitably  as  the  question  of  suffrage 
will  be  settled  by  granting  it  to  women,  just  as  inevitably  as  health  insurance 
and  industrial  accident  insurance  will  be  granted  by  the  public,  just  as  in- 
evitably as  orphan  children  will  be  reared  in  homes  rather  than  in  institutions 
because  these  measures  will  promote  the  broader  interests  of  human  welfare. 

Mr.  Koren: 

I  do  not  rise  to  have  the  last  word  in  support  of  my  views.  My  first  ex- 
perience in  the  study  of  this  subject  dates  back  about  twenty  years,  and  I 
have  endeavored  to  ascertain  the  truth  about  alcohol  not  only  in  the  United 
States  but  in  other  parts  of  the  world.  My  experience  is  that  upon  no  subject 
can  one  be  so  easily  misunderstood  because  of  preconceived  notions.  One 
or  two  corrections  I  should  like  to  make:  Dr.  Reed  must  not  understand 
that  I  mean  that  all  prohibition  legislation  has  been  enacted  because  of  the 
world-wide  or  state-wide  conviction  of  a  moral  kind.  I  am  speaking  of  the 
ultra  state  of  mind  behind  prohibition,  and  without  the  push  of  a  moral 
issue  many  states  would  not  have  accepted  prohibition.  I  have  already 
referred  to  the  apparent  misconception  of  what  I  said  about  the  attitude  of 
physicians.  I  merely  meant  that  the  medical  world,  so  far  as  I  have  been 
able  to  read — and  I  think  I  have  gone  over  all  the  literature — does  not  yet 
accept  the  teaching  that  every  use  of  alcoholic  drink  is  per  se  injurious. 
If  that  were  once  establisht,  the  public  would  come  to  believe  it,  and  we 
should  then  make  much  more  rapid  progress  with  our  legislation  against 
drinking.  My  quarrel  with  the  situation  is  not  that  we  do  not  need  legisla- 
tion, but  that  legislation  tends  to  outstrip  public  opinion  so  far  that  there 
is  not  a  sufficiently  strong  force  behind  the  law  and  that  being  the  case  the 
law  defeats  its  own  end.  My  position  is  that  we  should  approach  the  whole 
problem  in  another  way  and  more  gradually.  Therefore  I  referred  to  the 
Company  System  which  might  be  used  as  a  temporary  expedient  for  the 
education  of  people  to  a  state  of  mind  which  would  prepare  for  a  possible 
prohibition.  That  has  been  done  elsewhere.  In  Norway  the  Company 
System  brought  about  a  reduction  in  the  use  of  distilled  spirits  of  about 
one-half  twenty-five  years  ago.  That  has  not  been  accomplisht  anywhere 
else  so  far  as  I  know  under  any  other  regulations,  whether  prohibition,  or 
license  legislation.  In  Norway  up  to  the  present  time  no  sale  of  spirits  is 
allowed  except  in  quantities  of  250  gallons,  except  thru  these  privately 
organized  companies  and  they  receive  only  a  modest  return  on  the  earnings. 
In  many  communities  no  distilled  spirits  are  sold.  People  must  be  pre- 
pared if  at  all  for  state  wide  prohibition  by  some  such  expedient.  All  I  de- 
sire for  our  country  is  that  we  at  least  be  given  a  chance  to  try  out  progressive 
legislation.  With  the  personal  liberty  argument  I  have  no  patience.  I 
want  to  be  protected  against  the  drunkard,  but  I  want  to  see  whether  we 
cannot  by  some  law  educate  men  to  become  sober.    A  recent  addition  to  the 


153 

Norway  Company  System  is  the  Individual  System  of  Licensing.  A  man 
must  present  a  certificate  with  some  one  guaranteeing  that  he  will  not  abuse 
the  privilege  of  buying  spirits. 

Dr.  O.  H.  Lau,  Detroit: 

Did  I  understand  Mr.  Koren  to  say  that  it  has  not  been  determined  that 
the  drinking  of  alcohol  in  any  quantity  has  been  injurious? 

Mr.  Koren  (replying  to  Dr.  Lau) : 

The  over  use  of  alcohol  is  in  itself  injurious.     There  is  a  moderate  use  of 
alcohol  that  is  not  harmful  to  a  normal  individual. 


LEGISLATIVE   PROTECTION   OF  THE   PEOPLE   FROM 

THE  EVILS  OF  PATENT  MEDICINES  AND 

MEDICAL  FAKERS. 

By  F.  F.  Lawrbncb,  M.D.,  D.Sc,  LL.D.,  F.A.C.S.,  Columbus,  Ohio. 

Mr,  President,  Ladies  and  Gentlemen,  Members  of  the  Academy: 

There  are  two  distinct  propositions  to  be  discussed,  altho 
they  are  so  closely  allied  as  to  make  it  impossible  to  discuss  the 
one  without  discussing  the  other  also.  The  first  proposition  is 
"Legislative  Protection  of  the  People  from  the  Evils  of  Patent 
Medicines."  The  second  is  "Legislative  Protection  of  the  People 
against  Medical  Fakers."  In  order  that  we  can  understand  or 
measure  the  value  of  laws,  we  must  remember  that  legislation  is 
either  constructiv  or  correctiv. 

In  which  class  does  legislation  for  the  protection  of  the  public 
against  patent  medicines  and  medical  fakers  belong?  If  it  is 
to  be  classed  as  constructiv,  then  its  value  is  to  be  measured 
by  the  amount  it  contributes  to  the  education  of  the  public  to 
the  inherent  evil  of  patent  medicines  and  medical  fakers.  If  it 
is  to  be  classed  as  correctiv,  then  its  efficiency  is  to  be  measured 
by  the  curtailment  of  the  sale  of  nostrums  and  of  the  activities 
of  medical  fakers.  I  venture  the  assertion  that  these  curtail- 
ments have  been  a  negligible  quantity.  If  these  statements  be 
true,  there  must  be  a  WHY.  Is  it  possible  to  find  the  why,  and, 
if  found,  to  apply  it  to  the  solution  of  the  problem  ?  Let  us  analyze 
the  situation  and  study  it  under  the  following  heads : 

First.  One  important  evil  of  patent  medicines  is  the  habit- 
froming  drugs  contained  in  them.  These  have  not  been  eliminated 
by  the  Harrison  Law,  but  merely  decreased. 

Second.  The  other  most  important  evils  of  patent  medicines 
and  medical  fakerism  are  exactly  identical.     They  are  as  follows: 

a.  Improper  or  ignorant  treatment  frequently  produces  danger- 
ous effects. 

b.  They  lead  to  neglect  of  proper  treatment  in  many  cases  in 
which  only  surgery  can  accomplish  any  good,  until  it  is  too  late 
even  for  surgery,  hence  causing  unnecessary  sacrifice  of  life. 


155 

c.  They  produce  mental  and  physical  wrecks,  by  suggesting 
diseases  of  which  the  individual  previously  knew  nothing,  and  with 
which  he  was  never  afiiicted. 

d.  They  create  a  distrust  of  doctors  and  scientific  preventive 
medicine,  thus  breeding  various  "antis" — as  anti-vaccinationists,. 
and  anti-vivisectionists. 

Third.  The  inseparable  interests  of  patent  medicines  and  medical 
fakers  are: 

a.  The  credulity  of  the  public. 

h.  The  plausibility  of  the  advertisement. 

c.  The  financial  profit. 

d.  The  political  influence  of  a  large  bank  account. 

e.  The  ability  to  play  the  church  and  other  religious  or  philan- 
thropic organizations. 

/.  The  ease  with  which  a  comfortable  income  is  assured,  leading 
men  of  some  ability,  but  weak  courage,  into  the  patent  medicine 
business  or  the  practice  of  the  faker. 

g.  The  difficulty  of  the  honest  and  poor  doctor  contending  against 
these  combined  forces. 

h.  No  honest  potential  remedy. 

Fourth.  What  are  the  needs  of  the  public  and  its  desire  for 
protection?  Does  the  public  desire  legal  protection?  If  not, 
why  not? 

Fifth.  Past  endeavors  at  legislative  protection  against  patent 
medicines  have  been  partially  but  not  completely  successful. 
Why? 

Sixth.  A  faker  is  a  false  pretender,  no  matter  where  found. 
Many  such  are  harbored  within  the  profession. 

Seventh.  Unethical  advertising  methods  of  some  doctors  lead 
the  public  to  classify  them,  and  thru  them  the  entire  profession, 
with  advertising  quacks. 

Eighth.  Carelessness  among  doctors  tends  to  drag  the  profession 
down  to  the  level  of  the  patent  medicine  pedler  and  the  faker. 

Ninth.  The  profession  itself  is  responsible  for  the  hold  patent 
medicines  and  fakers  have  on  the  people. 

Tenth.  It  is  necessary  that  we  cleanse  the  profession  before  we 
can  hope  to  control  those  outside. 


156 

Eleventh.  Law  unenforced  is  impotent,  and  practical,  common 
sence  methods  only  will  lead  to  national  laws  strictly  enforced. 

Twelfth.  There  are  other  and  better  ways  to  effectively  attack 
the  evils  of  patent  medicines  and  fakers. 

Most  of  the  above  mentioned  evils  of  patent  medicines  and 
fakers  are  self-evident  to  any  medically  experienced  audience; 
but  one  or  two  points  might  be  expanded  upon. 

One  of  the  greatest,  if  not  the  greatest,  of  the  evils  of  patent 
medicines,  lies  in  the  suggestion  of  ills  of  which  the  reader  of  the 
advertisement  never  before  knew.  In  other  words,  the  patent 
medicine  advertiser,  by  shrewdly  wording  his  advertisement,  leads 
the  reader  to  believe  he  has  some  ill  for  which  the  particular  patent 
is  a  panacea.  This  particular  feature  of  the  patent  medicine 
business  is  as  potent  a  factor  for  ill  as  Christian  Science,  altho 
directly  the  opposite  in  its  action,  because  Christian  Science  may, 
and  often  does  lead  one,  afflicted  with  a  serious  disease,  to  believe 
he  is  not  ill,  while  the  patent  medicine  advertisement  leads  many 
perfectly  normal  men  and  women  to  believe  they  are  afflicted 
with  a  disease  which  only  the  particular  "patent"  will  cure. 

In  some  of  the  advertisements,  notably  the  Lydia  Pinkham's 
ghost,  the  errors  and  short-comings  of  the  medical  profession  are 
* 'played  up"  to  the  highest  point  of  efficiency.  Other  patent 
medicines  are  excelled  in  this  art  only  by  the  proprietary  medicine 
men,  who  thru  their  "detail  representatives"  secure  the  co-opera- 
tion of  doctors  and  buy  space  in  medical  journals  to  exploit  their 
preparations  in  a  manner  similar  to  the  "ready  to  wear"  clothing 
merchant. 

Do  the  people  want  legislative  protection,  and,  if  not,  why  not? 
It  is  quite  probable  that  the  "strenuous  life"  and  high  cost  of 
living  may  bear  some  relationship  to  the  attitude  of  the  public 
toward  medical  legislation.  It  is  a  fact  well  known  that  the  public 
is  too  busy  with  its  own  affairs  to  give  much  of  either  time  or 
thought  to  the  motive  back  of  an  advertisement.  In  other  words, 
the  psychological  effect  of  a  patent  medicine  advertisement  is 
produced  upon  the  public  mind  by  its  more  or  less  positive  sug- 
gestion of  cure  or  relief  from  physical  ills  at  a  nominal  expense 
to  the  individual,  without  exciting  any  effort  upon  the  part  of 


157 

the  individual  to  look  for  or  analyze  the  motive.  That  is,  the 
reader  does  not  feel  inclined  to  weigh  the  fact  that  the  advertiser 
has  something  to  sell,  and  that  the  prime  motive  of  the  advertiser 
is  to  create  a  demand  for  his  product  by  the  subtle  suggestion  of 
something  which  will  be  of  benefit  to  the  patient  at  less  cost  and 
with  more  positive  results  than  he  could  get  from  an  educated 
and  honest  physician.  He  simply  swallows  the  bait  (like  the  cat- 
fish), bait,  hook  and  a  good  part  of  the  line.  It  is  the  past  master's 
art  of  suggestion,  inasmuch  as  it  first  suggests  a  condition  or 
disease  and  then  suggests  a  remedy,  following  this  with  the  ever 
potent  suggestion  of  economy.  These  suggestions  are  so  skill- 
fully blended  as  to  make  them  each  helpful  of  the  other. 

It  might  be  pertinent  to  ask  in  what  way  has  any  legislation 
in  the  past  been  directed  to  the  lessening  or  overcoming  of  the 
influence  of  these  suggestions.  In  the  Federal  Pure  Food  legis- 
lation something  has  been  accomplished.  For  example:  a  syrup 
made  from  corn  cobs,  or  other  material,  cannot  be  sold  under  a 
label  of  "maple  syrup;"  but,  has  it  diminished  the  sale  of  "Maple- 
ine,"  or  other  imitations  of  maple  syrup?  Not  at  all!  It  is  pre- 
sumed that  the  individual  has  a  right  to  use,  as  food,  anything, 
not  violently  harmful,  that  he  may  like,  so  long  as  he  knows 
what  it  is.  Yet  this  is  probably  one  of  the  strongest  pieces  of 
Federal  legislation  against  pretention.  Of  course,  the  Anti- 
Narcotic  Law  must  be  given  first  place  in  practical  legislative 
effort.  But  has  the  legislation  against  the  sale  of  habit-forming 
nostrums  materially  lessened  the  sale  of  such  as  "Bull's  Cough 
Syrup,"  'Xydia  Pinkham's  Vegetable  Compound,"  "Peruna," 
"S.  S.  S.,"  or  any  one  of  a  host  of  others?  Apparently  not  to  any 
appreciable  extent. 

I  recently  visited  a  number  of  otu*  local  druggists,  and  asked 
them  what,  and  how  much  patent  medicines  they  were  now  selling, 
as  compared  to  the  past.  Without  exception,  they  answered  that 
they  sold  about  as  much  patent  medicines  as  they  ever  did.  Two 
stated  that  they  were  selling  more.  All  mentioned  the  nostrums 
I  have  named  above  as  being  the  leaders  in  sales. 

If  this  condition  exists  among  the  druggists  in  one  city,  is  it 
not  quite  probable  that  the  same  condition  is  more  or  less  universal? 


158 

(A  lack  of  time,  since  accepting  your  Secretary's  invitation,  pre- 
vented me  making  an  extensive  inquiry  from  druggists  in  many 
cities.) 

The  foregoing  would  seem  to  lead  to  the  conclusion  that,  as 
far  as  the  patent  medicine  evil  is  concerned,  legislation  cannot  be 
effective  unless  it  be  directed  toward  the  psychic  suggestion  of  the 
form  of  the  advertisement  in  such  manner  as  to  positively  control 
the  publication  and  distribution  of  testimonials. 

Considering  the  reason  why  legislation  in  the  past  has  not 
diminished  the  sale  of  patent  medicines,  it  is  pertinent  to  note 
the  opinions  of  several  druggists. 

One  who  is  both  a  wholesale  and  retail  dealer  says,  "The  testi- 
monials distributed  by  circular  and  published  in  newspapers  keep 
up  the  sale  of  patent  medicines."  Another  says,  "Patent  medi- 
cines will  be  sold  just  as  long  as  the  patent  medicine  men  can 
hire  those  who  have  a  modicum  of  medical  education  added  to 
a  keen  business  insight,  to  direct  their  advertising  department." 
Another  prominent  North  High  Street  druggist  says,  "Patent 
medicines  will  be  sold  as  long  as  newspapers  advertise  them  and 
people  will  send  them  testimonials."  These  are  three  of  over 
twenty-five  statements  of  like  character  by  druggists. 

This,  then,  is  a  concrete  statement  of  the  fact — legislation  which 
does  not  reach  the  cause  can  never  cure  the  effect.  Can  legis- 
lation be  enacted  which  will  strike  at  the  root  of  this  matter? 
I  doubt  that  legislation  can  be  enacted  which  would  prove  consti- 
tutional at  the  present  time.  It  may  be  that  after  a  few  more 
years  of  education,  the  public  and  our  courts  may  be  so  developed 
as  to  see  the  need  of  sustaining  such  a  measure,  when  passed  by 
a  legislative  body,  or  even  to  aid  in  securing  such  a  measure. 
The  more  you  or  I  face  this  problem  squarely,  the  more  will  we 
be  convinced  that  the  real  remedy  lies  in  our  own  hands,  but  it 
means  endless,  honest  work.  This  work  is  so  closely  connected 
with  our  second  proposition  that  I  will  discuss  that  now, — 

"THS  PROTECTION   OF  THE  PUBI.IC  FROM  MEDICAI.  FAKERS." 

What  is  a  medical  faker?  Is  the  term  to  be  limited  to  him  who 
has  NO  medical  training  and  pretends  the  same,  or  is  it  to  include 


159 

all  who  really  fake,  even  tho  they  have  M.D.,  A.M.,  or  other 
addenda  to  their  names?  Is  the  great  surgeon  who  permits 
his  name  to  appear  in  a  magazine  section  of  the  New  York  Times 
as  ''never  having  had  a  failure''  any  less  a  faker  than  the  street 
vender  with  his  wig  and  monkey?  I  hear  a  hearty  NO!  Is  the 
ignorant  pretender  more  culpable  than  the  educated  faker? 
There  is  a  scripture  which  seems  quite  applicable  here.  "For 
without  the  law  sin  was  dead,  but  the  law  came  and  sin  revived." 
This  is  to  say  that  the  man  who  knows  no  scientific  law  must  be 
less  culpable  than  the  one  who  knows  some  or  much  scientific 
law! 

Is  it  a  fake  for  a  man  to  claim,  either  thru  medical  journals 
or  lay  papers,  to  have  "treated  a  case  hitherto  unknown,  or  to 
have  performed  an  operation  which  was  the  first  of  its  kind  ever 
performed" — when  the  truth  of  the  matter  is  the  pages  of  our 
medical  journals  and  text  books  show  such  cases  to  have  been 
known,   treated  and  operated  upon  years  before? 

You  and  I  know  that  advertisement  is  as  necessary  to  the  doctor 
as  it  is  to  the  merchant.  The  only  quibble  is  as  to  the  form,  and 
the  truthfulness. 

As  to  the  form — the  doctor  of  olden  times  believed  that  "By 
their  fruits  ye  shall  know  them,"  and  relied  upon  the  advertise- 
ment from  mouth  to  ear.  This  method  of  advertisement  was  slow. 
It  did  not,  and  never  has  yet,  produced  a  very  large  following. 
The  first  step  in  getting  away  from  this  was  the  establishing  of 
medical  colleges  for  the  sole  purpose  of  advertising  its  promoters, 
and  we  had  many  kinds,  as  we  still  have  many  cults  for  the  same 
purpose,  cults  taking  the  place  of  former  cheap  schools.  It  was 
and  it  is  yet  said  to  be  very  unprofessional  to  advertise  in  lay 
newspapers  and  pay  for  the  space  the  same  as  the  commercial 
man  pays.  But  there  is  one  strange  thing,  in  that  it  seems  to  be 
professional  if  we  can  "work"  the  newspapers  for  a  magazine  sec- 
tion advertisement  under  the  guise  of  news  and  not  pay  for  it. 
You,  who  know  the  business  side  of  the  newspaper  world,  know 
very  well  that  the  business  manager  of  a  Metropolitan  newspaper 
is  not  a  philanthropist,  and,  knowing  that,  you  also  know  equally 
well  that  all  these  advertisements  have  been  paid  for  either  di- 


i6o 

rectly  or  indirectly,  and  you  also  know  that  it  is  the  acme  of 
hypocrisy  for  anyone  to  assume  an  air  of  injured  innocence  in 
case  of  flambuoyant  magazine  section  advertisements. 

It  is  a  very  difi&cult  and  probably  thankless  task  to  attempt  the 
correction  of  this  thing.  I  am,  however,  thoroly  convinced  that 
if  we  are  to  succeed  in  securing  such  legislation  as  can  be  enforced 
to  control  patent  medicine  evils  and  to  abolish  medical  fakers, 
we  must  in  sincerity  and  force,  first  abolish  this  iniquitous  system 
of  "working  the  newspapers  for  free  advertisement  of  prominent 
men." 

How  can  you,  reasonably,  expect  the  public  to  believe  that  a 
patent  medicine  cannot  be  made  to  fit  its  needs  if  a  doctor  is  ever 
ready  to  dish  out  an  envelope  filled  with  "ready  to  serve  pills  or 
tablets"  or  prescribes  a  fluid  preparation  which  is  poured  out  by 
the  druggist  from  a  bottle  bearing  a  label  as  grotesque  as  any  on 
the  patent  medicine  bottle? 

Or  in  a  surgical  case,  how  can  you  reasonably  expect  the  lay- 
man to  think  there  is  any  virtue  in  asepsis  or  antisepsis,  if  he  go 
into  a  doctor's  office  with  a  wound  and  the  doctor  unwraps  a  roll 
of  cotton  from  a  paper  wrapper,  without  washing  his  hands,  picks 
up  an  instrument  from  a  dust  covered  stand,  and  proceeds  to 
infect  the  wound?  And  yet  such  things  are  common  among  the 
profession.  If,  then,  the  public  does  not  see  the  importance  of, 
nor  desire  legislative  protection  against  patent  medicines  and 
fakes,  whose  is  the  fault?  We  play  into  the  hands  of  the  patent 
medicine  men  and  the  fakers  by  these  unscientific  and  careless 
methods.  At  the  same  time  we  have  utterly  failed  to  take  note 
of  the  fact  that  the  patent  medicine  men  exert  an  influence  over 
the  public  mind  thru  their  advertisements,  in  which  they  com- 
bine all  the  arts  of  suggestive  therapy.  Christian  Science,  vito- 
therapy  and  financial  economy. 

There  can  be  no  question  about  the  sacrifice  of  life  or  of  the 
wreckage  of  health  which  is  constantly  the  result  of  patent  medi- 
cines and  medical  fakers,  but  the  responsibility  for  the  hold  they 
have  on  the  public  rests  upon  the  shoulders  of  the  medical  pro- 
fession to  a  considerable  extent,  because — 


i6i 

First.  We  have  not  taken  the  people  into  our  confidence  enough 
to  educate  them  to  their  needs. 

Second.  As  a  profession,  we  have  not  publicly  taken  any  action 
toward  condemning  members  of  the  profession  for  the  acts  above 
referred  to. 

Third.  There  has  been  no  positive  action  taken  by  our  medical 
societies  looking  to  the  curtailment  of  these  activities. 

Fourth.  The  American  College  of  Surgeons  was  organized  with 
the  avowed  purpose  of  controlling  some  of  the  evils,  chief  of 
which  was  fee  splitting,  and  in  its  inception  some  of  those  who 
had  been  most  active  practicers  of  these  evils  were  made  charter 
members.  They  kept  other  men  out  by  objections  and  have 
tried  by  malicious  letters,  and  otherwise,  to  injure  members  or 
Fellows  who  have  never  been  known  to  split  fees  or  commit  any 
other  professional  wrong.  The  general  public  soon  finds  these 
things  out,  recognizes  the  Phariseeism,  and  is  quick  to  resent  an 
espionage  by  such  men. 

The  fee  splitter  will  continue  to  split  fees,  and  the  faker  wdll 
continue  to  advertise  his  wares  with  the  approval  of  the  public 
until  we,  as  a  profession,  cease  to  commend  or  recommend  in 
any  way  whatsoever,  men  who  flagrantly  violate  every  sense  of 
professional  ethics  and  refinement.  We  cannot  reasonably  ask 
or  secure  enforcable  laws  to  restrict  the  faker  in  his  operations 
unless  we  actively,  positively  and  effectually  control  the  adver- 
tising activities  of  the  prominent  men  in  our  profession.  In  other 
words,  the  profession  must  come  wath  clean  hands,  if  it  expects 
to  demand  of  the  public  support  in  controlling  fakers.  The  neces- 
sity may  be  ever  so  great,  but  the  people  cannot,  and  will  not,  see 
any  line  of  demarcation  between  professional  humbuggery  and 
the  humbuggery  of  the  faker,  and  we  must  be  honest  enough  to 
own  that  there  is  only  a  slight  moral  difference,  and  that  is  in 
favor  of  the  faker ,  because  he  is  not  as  well  educated  or  trained 
as  the  professional  man,  and  consequently,  cannot  be  expected 
to  see  the  real  scientific  and  moral  refinements  with  as  clear  vision 
as  the  educated  doctor  should. 

Then  if  we  have  fakers  and  advertisers  inside  the  profession  and 
do  not  attempt  to  discipline  them  professionally,  what  right  have 


l62 

we  to  seek  legislative  restriction  for  those  outside,  whose  educa- 
tion is  not  equal  to,  and  whose  appreciation  of  the  responsibilities 
must,  therefore,  be  less  than  those  medically  trained?  It  is 
an  absolutely  fair  proposition. 

How  canst  thou  say  to  thy  brother,  Brother,  let  me  pull  out  the  mote  that 
is  in  thine  eye,  when  thou  thyself  beholdest  not  the  beam  that  is  in  thine 
own  eye?  Thou  hypocrite!  cast  out  first  the  beam  out  of  thine  own  eye, 
and  then  shalt  thou  see  clearly  to  pull  out  the  mote  that  is  in  thy  brother's 
eye. 

Can  we,  as  a  profession,  consistently  ask  legislators  to  enact 
laws  to  control  the  other  fellow's  short-comings,  which  are  no 
worse  than  our  own,  so  long  as  we  have  done,  and  are  doing, 
nothing  in  our  medical  organizations  to  eradicate  professional 
buncombe?  Is  it  not  time  that  we  be  honest  with  ourselves? 
Is  it  not  high  time  that  we  see  to  it  that  our  profession  is  far  above 
reproach  ere  we  spend  so  much  effort  to  reform  the  other  fellow? 
I  believe  that  you  will  agree  with  me  that  it  is  of  prime  import 
that  we  first  cleanse  our  own  stables  ere  we  undertake  the  task 
of  cleansing  the  Augean  stables  of  the  fakers  and  patent  medicine 
men  of  the  filth  and  accumulation  of  years,  due  to  our  own  neglect. 
Hercules  was  able  to  command  the  waters  of  the  two  rivers, 
Alpheus  and  Peneus,  to  cleanse  the  Augean  stables,  and  we  must 
be  able  to  command  the  waters  of  courage,  conscience,  character 
and  common  sense,  if  we  are  to  clean  and  purify  the  public  mind 
of  the  filth,  foibles  and  falsity  which  have  accumulated  thru  years 
of  activity  on  the  part  of  patent  medicines  and  fakers,  and  culpable 
neglect  upon  the  part  of  the  profession.  These  are  unpleasant 
truths,  I  know,  but  that  they  are  truths,  I  challenge  any  man  to 
controvert. 

Then  the  first  legislation,  to  be  of  effect  against  medical  fakers, 
must  be  such  legislation  in  our  medical  organizations,  strictly 
enforced,  as  will  prevent  faking  by  any  member  of  the  profession. 

National  and  state  laws  have  been  enacted  to  correct  some  of 
the  evils  we  are  discussing,  but  most  of  them  are  not  enforceable 
because  the  evidence  cannot  be  obtained.  These  laws  do  no  good, 
but,  on  the  contrary,  do  much  to  minimize  the  influence  of  the 
medical  profession  by  the  failure  in  enforcement.     One  law  thoroly 


i63 

enforced  is  of  more  value  than  one  hundred  which  are  openly  defied. 

To  epitomize  a  few  suggestions : 

First.  It  is  not  more  legislation  that  is  needed,  but  better,  truer 
and  more  complete  education. 

Second.  The  education  of  the  public  in  the  patent  medicine 
heresy  is  only  to  be  accomplished  by  and  thru  the  medical  pro- 
fession, and  in  order  to  accomplish  practical  results,  each  member 
of  the  profession  must  be  an  active  committee  of  one  to  instruct 
his  clientele  and 

Third.  The  printed  matter  which  goes  to  the  public  must 
not  be  limited  to  the  newspaper  advertisements  of  patent  medi- 
cines and  fakers  and  the  circulars  of  testimonials  sent  out  by  them, 
but  the  profession  should  establish  and  publish  a  common  sense 
journal  for  the  people,  to  contain  articles  by  honest  men,  telling 
them,  in  plain  words,  the  truth,  and  without  assuming  anything 
fantastic. 

Fourth.  How  are  you  going  to  frame  a  law  which  will 
reach  the  patent  medicine  evil?  It  can  only  be  done  by  direct 
attack  upon  the  form  of  advertisement.  This  attack  may  be 
delivered  in  both  of  two  ways. 

a.  By  sectuing  co-operation  of  advertising  agencies,  newspapers, 
magazines,  etc.,  to  restrict  the  form  and  character  of  advertise- 
ments to  statements  of  truth  only. 

h.  By  Federal  and  state  legislation  to  control  the  form  and 
character  of  all  advertisements.  The  question  then  is,  can  such 
a  law  be  constitutional? 


STANDARDS  APPLICABLE  TO  CHILD  LABOR. 

By  Hblbn  L.  Sumner,  Ph.D.,  Assistant  Chief,  U.  S.  Children's  Bureau,  Washington,  D.  C. 

In  these  days  of  anxiety  over  war  the  need  of  considering 
thoughtfully  how  to  bring  up  the  younger  generation  sound, 
healthful,  and  unstunted  in  growth  has  become  apparent  even  to 
the  layman  who  has  no  interest  in  social  problems.  It  is  well 
known  that  thousands  of  applicants  for  enlistment  in  the  United 
States  Army  are  refused  because  unable  to  pass  the  physical 
test.  Yet  this  country  is  deplorably  behind  European  coun- 
tries in  gathering  data  as  to  the  physical  condition  of  children.  ^ 
It  is  well  known  that  every  growing  body  is  peculiarly  liable 
to  injury  from  overstrain  and  is  peculiarly  sensitive  to  all  sorts 
of  industrial  hazards.  Yet  so  far  as  I  have  been  able  to  discover, 
the  only  investigation  of  the  effects  of  child  labor  on  the  growth  of 
the  body  ever  made  in  this  country  is  the  series  of  measurements 
of  working  and  school  children  now  being  made  by  Dr.  Helen  T. 
Woolley,  of  Cincinnati.^  Four  years  ago  Dr.  Teleky,  of  Austria, 
at  the  meeting  of  the  International  Congress  of  Hygiene  and 
Demography  at  Washington,  urged  that  those  having  an  oppor- 
tunity for  such  study  should  report  as  to  the  physical  effects 
of  industrial  labor  on  children.^  Yet  we  still  have  little  besides 
d  priore  reasoning  on  which  to  base  a  judgment  as  to  the  effects 
of  occupations  on  growing  human  bodies. 

In  considering  physical  and  probably  all  other  standards  ap- 

1  The  first  systematic  series  of  measurements  of  children  in  this  country  appears  to 
have  been  that  made  by  Dr.  Bowditch,  of  Harvard,  forty  years  ago.  Bowditch,  H.  P.: 
"The  Growth  of  Children."  Boston,  1877.  (In  Massachusetts  State  Board  of  Health, 
8th  annual  report,  pp.  275-323.) 

»  For  preliminary  report  of  this  investigation  see  Woolley,  Helen  T.,  and  Fischer, 
Charlotte  R:  "Mental  and  Physical  Measurements  of  Working  Children."  Psychological 
Review,  Monograph,  December,  1914,  V.  18,  No.  1. 

»  Teleky,  Ludwig:  "Altersprobleme  gewerblicher  Hygiene."  (In  15th  International 
Congress  of  Hygiene  and  Demography,  Wash.,  1912,  Transactions,  V.  3,  Pt.  2:  "Hygiene 
of  Occupations,  "pp.  957-974.) 


i65 

plicable  to  child  labor,  all  minors  should  be  classified  as  children. 
The  age  of  attaining  majority,  coming  as  it  does  near  the  period 
when  growth  is  completed,  is  a  fairly  close  approximation  to 
the  physiological  end  of  childhood.  Legally,  moreover,  a  minor 
is  under  the  guardianship  of  the  state,  which  has  an  unquestioned 
right  to  abridge  his  freedom  of  contract  or  to  impose  upon  him 
any  regulation  deemed  to  be  in  his  interest.  On  the  one  hand, 
the  minor  is  peculiarly  subject  to  regulations  calculated  to  es- 
tablish standards  for  his  protection  because  of  his  legal  status 
as  a  ward  of  the  state,  and,  on  the  other  hand,  he  is  peculiarly  in 
need  of  the  establishment  of  such  standards  because  of  his  weak- 
ness and  because  his  organism  is  carrying  a  double  burden,  that 
of  self-renewal  and  that  of  growth. 

The  problem  is  only  in  part  to  be  solved  by  prohibiting  child 
labor.  Under  modern  industrial  conditions  the  young,  immature 
body  and  mind  must  inevitably  be  injured  by  the  strain  of  keep- 
ing pace  with  a  machine,  by  carrying  heavy  weights,  or  by  work- 
ing under  abnormal  conditions  of  temperature,  humidity,  dust, 
or  fumes.  An  age  standard  for  entrance  into  industry  has  there- 
fore been  established.  In  this  country  the  minimum  age  for  em- 
ployment in  industrial  occupations  is  generally  fourteen  and  in 
many  states  children  under  sixteen  may  not  be  employed  in 
processes  which  are  believed  to  involve  unusual  risk.  These 
ages,  it  is  highly  probable,  will  be  raised  by  two  years  each  within 
the  next  decade,  particularly  if  investigations  of  the  physical 
effects  of  child  labor  demonstrate  the  need  for  such  changes. 
But  during  an  unforeseeable  future  the  vast  majority  of  young 
people  will  enter  some  gainful  occupation  before  their  physical 
growth  is  entirely  completed,  and  the  standards  to  be  applied  to 
the  work  of  these  young  people  constitute  a  vitally  important 
part  of  the  problem  of  child  labor. 

Two  kinds  of  standards  must  be  considered,  those  applying 
to  entrance  into  industry  and  those  applying  to  conditions  and 
character  of  work  after  entrance  into  industry.  Of  the  standards 
appHcable  to  entrance  into  industry  the  principal  ones  actually 
in  use  relate  to  age,  to  education,  and  to  physical  condition. 


i66 

Age  is  a  fairly  well-defined  standard,  yet  Dr.  Rotch  and  others^ 
have  pointed  out  the  marked  difference  between  the  chronologic 
and  the  physiologic  age  of  children  and  have  urged  that  the 
stage  of  physiologic  development  be  taken  into  account  in  con- 
nection with  the  years  of  life.  The  desirability  of  doing  this  is 
brought  home  to  anyone  who  visits  an  office  where  working 
papers  are  issued  to  children  from  fourteen  to  sixteen  years  of 
age  and  sees  strapping  young  boys  and  girls — strong  perhaps 
only  in  appearance — side  by  side  with  small,  undeveloped  chil- 
dren. In  several  states,  if  a  child  cannot  produce  documentary 
evidence  of  his  age,  he  is  given  a  physical  examination  to  deter- 
mine whether  he  is  probably  over  fourteen.  But  as  in  such  cases 
the  aim  is  to  secure  an  approximation  to  chronologic  age,  no 
method  similar  to  that  advocated  by  Dr.  Rotch,  of  taking  a  radio- 
graph of  the  bones,  is  used.  Indeed,  the  development  of  the  teeth 
seems  to  be  more  often  relied  upon  than  any  other  single  factor 
in  giving  a  physician's  certificate  of  age. 

Educational  standards  for  entrance  into  industry  differ  widely 
but  only  rarely  is  any  provision  made  for  the  various  mental 
states.  Yet  children  applying  for  working  papers  grade  from 
the  exceptionally  bright  down  to  mental  defectives.  Out  of  fifty 
unselected  children  who  had  gone  to  work  at  fourteen,  after  hav- 
ing completed  the  fifth  grade,  and  who  were  tested  by  the  Yerkes 
point  scale  at  eighteen  years  of  age.  Dr.  WooUey  found  that 
13,  or  about  one-fourth,  belonged  in  the  class  of  mental  defec- 
tives, while  15,  or  more  than  another  fourth,  were  border-line 
cases.2  Fourteen  years  is  generally  regarded  as  the  average 
age  for  completion  of  the  eighth  grade,  and  many  people  are  sur- 

*  Rotch,  Thomas  M.:  "Chronologic  and  Anatomic  Age  in  Early  Life,"  Journal  of 
the  American  Medical  Association,  1908,  51,  1197-1203.  "The  Labor  and  Work  of 
Children  Should  Be  Adapted  to  the  Individual  Child."  (In  15th  International  Congress 
of  Hygiene  and  Demography,  Wash.,  1912,  Transactions,  8,  Pt.  2:  "Hygiene  of  Occupa- 
tions," pp.  975-984.) 

Crampton,  C.  Ward:  "Physiological  Age;  a  Fundamental  Principle."  American 
Physical  Education  Review,  IS,  141-154,  214-227,  268-283,  345-358  (1908). 

"The  Significance  of  Physiological  Age  in  Education."  (In  15th  International  Con- 
gress of  Hygiene  and  Demography,  Wash.,  1912,  Transactions,  3,  Pt.  1:  "Hygiene  of 
Infancy  and  Childhood,"  pp.  224-236.) 

*  Woolley,  Helen  Thompson:  "A  New  Scale  of  Mental  and  Physical  Measurements 
for  Adolescents  and  Some  of  Its  Uses,"  Journal  of  Educational  Psychology,  November. 
1915. 


i67 

prised  to  find  that  among  fourteen-year-old  children  applying 
for  working  papers  completion  of  the  eighth  grade  is  the  exception 
rather  than  the  rule.  If  children  were  required  to  have  completed 
the  eighth  grade  before  going  to  work,  few,  if  any,  mental  defec- 
tives could  secure  working  papers  before  they  were  sixteen. 
Under  a  law  recently  enacted  in  New  York  State,  ^  no  child  un- 
der fifteen  can  work  without  a  certificate  of  graduation  from  the 
eighth  grade,  and  this  is  regarded  as  practically  raising  the  min- 
imum age  to  fifteen  years.  In  a  state  like  Massachusetts,  which 
requires  completion  of  only  the  fourth  grade,  many  mental  de- 
fectives must  enter  industry  on  exactly  the  same  basis  as  normal 
children.  Yet  these  mental  defectives  are  undoubtedly  subject 
to  greater  risk  in  industry  than  are  normal  children. 

A  dozen  or  more  states^  require  every  child  to  be  examined 
by  a  physician  and  to  be  declared  either  "in  sound  health"  or 
"physically  able  to  perform  the  work  which  he  intends  to  do," 
or  both,  before  working  papers  will  be  issued.  Sometimes  this 
physical  examination  is  supposed  to  be  repeated  each  time 
the  child  changes  his  position,  and  in  Maryland  each  time  he 
changes  his  occupation.  In  states  requiring  re-examination  on 
change  of  position,  the  examination  is  supposed  to  have  refer- 
ence to  the  particular  occupation  and  the  child  is  therefore  re- 
quired to  bring  a  promise  of  employment  signed  by  the  prospec- 
tive employer  and  stating  the  occupation  in  which  he  is  to  be 
engaged.  But  studies  of  the  administration  of  child  labor  laws 
made  by  the  Children's  Bureau  have  shown  that  physicians 
giving  the  physical  examination  rarely  if  ever  have  enough  knowl- 
edge of  occupations  to  say  that  a  particular  child  should  not  en- 
gage in  one  occupation,  but  may  safely  engage  in  another.  Some 
physicians  have  told  us  that  they  would  n4t  give  a  child  with 
heart  trouble  a  certificate  to  run  errands,  but  these  same  physi- 
cians, through  ignorance  of  the  duties  involved,  might  give  such 
a  child  a  certificate  to  work  in  an  occupation  which  would  involve 
cany^ng  heavy  weights  up  and  down  stairs.  In  England  the 
certifying  siu-geons  themselves  study  at  first  hand  the   occupa- 

1  New  York  Laws  of  1916,  Chap.  465.  effective  Feb.  6.  1917. 

*  Sumner,  Helen  L.,  and  Merritt,  Ella  A.:     "Child  Labor  Legislation  in  the  United 
States."     (U.  S.  Children's  Bureau,  Publication  10.     Industrial  Series  No.  1.) 


i68 

tions  for  which  they  give  certificates.  But  in  this  country  we 
pay  our  physician  only  for  making  the  physical  examinations 
and  make  no  provision  for  scientific  study  of  occupations,  either 
by  the  examining  physician  or  by  anyone  else.  When  such  studies 
are  made  it  is  to  the  credit  of  the  individual  physician  and  not 
of  our  system.  In  states  requiring  intelligent  discrimination 
between  occupations,  serious  need  exists  for  the  establishment, 
through  careful  study  of  the  different  kinds  and  degrees  of  strain 
involved,  of  an  occupational  standard  or  measuring  rod  by  which 
a  physician  can  determine  what  occupations  each  individual 
child  can  engage  in  without  the  probability  of  injury. 

When  the  law,  on  the  other  hand,  requires  that  the  child  shall 
be  in  "sound  health"  certifying  physicians  are  in  great  need  of 
a  standard  of  measurement  for  "sound  health."  New  York,  for 
example,  has  such  a  law  and  in  some  cities,  notably  Rochester, 
children  are  required  to  have  their  teeth  put  in  order  before  they 
can  go  to  work,  whereas  in  other  cities  little  or  no  attention  is 
paid  to  the  condition  of  the  teeth.  ^  When  the  law  adds  that  the 
child  must  be  of  normal  development  for  his  age,  physicians 
need  to  know  what  is  normal  development  for  children  of  differ- 
ent ages.  Recently  a  pamphlet  has  been  published  containing 
a  statistical  study  of  the  heights  and  weights  of  applicants  for 
working  papers  in  New  York  City,^  with  a  view  to  establishing 
standards  of  height  and  weight  at  different  ages  from  fourteen 
to  sixteen  for  the  use  of  certifying  physicians.  But  European 
studies  have  demonstrated  that  children  of  the  working  classes 
are  shorter  and  lighter  than  children  of  the  upper  classes.^  Are 
we  to  be  satisfied  in  this  country  with  a  standard  of  "normal 
development"  based  on  a  group  of  children  who  are  probably 
underdeveloped  ? 

Another  standard  which  ought  to  be  applied  before  entrance 
into  industry  relates  to  the  choice  of  occupations.     In  many 

»  Sumner,  Helen  L.,  and  Hanks,  Ethel  E.:  "Employment  Certificate  System  in  New 
York."      (U.  S.  Children's  Bureau,  Publication  17.     Inaustrial  Series,  No.  2.  Pt.  2,  p.  48.) 

»  Frankel,  Lee  K.,  and  Dublin,  Louis  I.:  "Heights  and  Weights  of  New  York  City 
Children  14  to  16  Years  of  Age;  A  Study  of  the  Measurements  of  Boys  and  Girls  Granted 
Employment  Certificates."     Metropolitan  Life  Insurance  Company,  N.  Y.,   1916. 

»  Loriga,  Giovanni:  "Lavoro  dei  fanciuUi  e  cresceuza  del  corpo."  (Italy.  Ministero 
di  agriculture,  industria  e  commercio.     UflScio  del  Lavoro,  1910.) 


i6g 

cities  in  Germany  the  school  physician  gives  advice  to  children 
leaving  school  for  work  as  to  the  kind  of  occupations  for  which 
they  are  by  nature  fitted.  Such  advice,  in  the  light  of  Mrs. 
Woolley's  experiments,  ought  to  take  into  consideration  both 
physical  and  mental  status.  Vocational  education  of  children 
should  also  have  regard  to  these  two  factors.  For  this  reason, 
if  for  no  other,  all  school  children  should  be  examined  periodically 
to  determine  their  state  of  physical  and  mental  growth,  and  the 
results  of  such  examinations  should  be  placed  before  vocational 
counsellors  and  before  physicians  who  are  required  to  certify  to 
the  children's  fitness  for  work.  Advice  as  to  choice  of  occupa- 
tions, however,  can  be  given  only  by  persons  who  are  thoroughly 
acquainted,  often  as  a  result  of  personal  observation,  with  the 
requirements  of  the  various  vocations. 

At  present  the  most  poorly  defined  standard  for  entrance  into 
industry  is  the  physical.  The  same  thing  is  true  of  standards 
applicable  to  character  and  conditions  of  work  after  entrance  into 
industry.  A  priori  we  know  that  a  child  is  peculiarly  suscepti- 
ble to  all  industrial  hazards,  including  injury  from  overstrain. 
We  know  that  some  occupations  involve  overexercise  of  one  set 
of  muscles  and  underexercise  of  all  others;  that  in  some  there  is 
too  much  sitting  and  in  others  too  much  standing;  that  in  some 
children  are  obliged  to  carry  weights  far  beyond  their  strength 
and  that  in  others,  particularly  agricultural  labor,  they  are  fre- 
quently deprived  of  sufficient  sleep.  Austrian  sickness  insurance 
records  show  that  frequency  of  invalidity  is  extremely  high  among 
youthful  laborers.^  It  is  noticeable,  moreover,  that  the  invalidity 
rate  is  not  the  greatest  at  the  age  of  fotuteen,  immediately  upon 
entry  into  industry,  but  becomes  alarming  diuring  the  second 
year  of  working  life  when  the  injurious  results  of  the  occupation 
have  had  time  to  show  themselves.  The  experience  of  German 
invalidity  funds  confirms  this  result.  ^  Accidents  are  also  known 
to  be  abnormally  frequent  among  yoimg  workers.  And  the 
Federal  Bureau  of  Labor^  has  shown  that  in  the  city  of  Fall 
River,  Mass.,    the   death   rate   from   tuberculosis   among  boys 

1  Teleky,  Ludwig,  op.  cit. 

*  Report  on  Condition  af  Women  and  Child  Wage-Earners,  Vol.  14,  "Causes  of  Death 
among  Cotton  Mill  Operatives."  p.  75. 


170 

15  to  19  years  of  age  employed  in  cotton  mills  was  nearly  double 
that  of  boys  not  so  employed,  and  that  similar  rates  for  girls 
of  the  same  ages  show  even  a  greater  difference. 

The  evils  of  child  labor,  however,  cannot  be  measiwed  primarily 
by  the  incidence  of  the  ordinary  occupational  injuries  and  dis- 
eases to  which  both  adults  and  children,  in  varying  degrees,  are 
liable.  Records  of  occupational  injuries  and  diseases  are  being 
collected  at  the  Massachusetts  General  Hospital  and  also,  I 
understand,  at  some  of  the  hospitals  in  Philadelphia,  and  these 
records  may  in  time  give  us  statistics  showing  the  relative  lia- 
bility of  children  and  of  adults  to  such  ill  results  of  labor.  But 
except  for  Dr.  WooUey's  measurements  of  height  and  weight 
nothing,  so  far  as  I  know,  is  being  done  in  this  country  to  throw 
the  light  of  science  upon  the  effects  of  occupations  upon  the  growth 
of  the  body — the  real  primary  test  of  child  labor. 

Some  years  ago  a  pamphlet  on  this  subject,  written  by  Pro- 
fessor Loriga,  of  the  University  of  Rome,  was  published  by  the 
Italian  Labor  Bureau.  ^  In  this  pamphlet  Professor  Loriga  gath- 
ered together  the  results  of  all  the  scientific  studies  of  the  effects 
of  child  labor  on  the  growth  of  the  body  which  up  to  that  time 
had  been  made  in  any  country. 

Professor  Loriga's  conclusions  are:  first,  that  the  period  when 
vitality  is  needed  for  the  growth  of  the  body,  and  not  merely 
for  its  maintenance,  ends  only  between  the  twentieth  and  twenty- 
fifth  years;  second,  that  in  every  comparison  of  height,  weight, 
and  lung  capacity  of  children  of  wealthy  and  of  poor  parents, 
great  differences  in  favor  of  the  wealthy  classes  are  shown;  third, 
that  similar  measurements  of  working  and  non-working  children 
show  great  differences  in  favor  of  the  non-working  children; 
and,  fourth,  that  comparisons  of  the  height  and  weight  of  con- 
scripts from  different  occupations  demonstrate  conclusively 
that  after  the  normal  age  for  growth  has  passed  it  is  impossible 
ever  to  repair  the  damage  done  by  conditions  which  have  retarded 
or  caused  uneven  development.  He  admits  that  heredity  plays 
an  important  part,  but  maintains  that  heredity  merely  fixes  an 
average  around  which  there  is  ample  room  for  individual  varia- 
» Op.  cit. 


171 

tions.  The  more  favorably  situated  tend  to  attain  the  maximum 
while  the  ill-nourished  and  hard-worked  tend  to  fall  to  the  min- 
imum possible  to  their  heredity.  The  most  important  period 
of  growi:h,  he  says,  the  period  during  which  "the  organic  needs 
are  most  exacting  in  their  demands  upon  the  energy  of  the  young," 
is  the  period  of  adolescence,  extending  from  the  twelfth  to  the 
eighteenth  year — the  very  period  "during  which  children  are 
permitted  to  begin  manual  labor  and  are  often  exposed  im- 
mediately to  its  most  serious  hardships."  The  author  calls  atten- 
tion to  the  great  importance  to  health  and  strength  of  every 
deviation  from  the  normal  in  the  form  of  the  skeleton  and  main- 
tains that  malformations  and  arrested  development  are  fre- 
quently caused  by  too  early  labor. 

Though  Professor  Loriga  fiuiiher  maintains  that  not  all  conse- 
quences of  early  labor  are  visible  and  measurable,  he  advocates 
periodic  medical  examinations  of  all  children  at  work  to  deter- 
mine whether  their  state  of  health  and  of  growth  appear  to  justify 
their  further  employment  and  to  discover,  in  so  far  as  possible, 
the  injurious  influences  of  occupations  before  the  resulting  in- 
juries become  of  pathological  importance.  "In  other  words," 
he  says,  "the  medical  visit  should  establish  in  what  degree  the 
bodily  development  of  working  children  progresses  under  the 
influence  of  labor." 

Perhaps  the  most  important  consequences  of  early  labor  which 
are  not  capable  of  immediate  and  direct  measurement  are  those 
resulting  from  fatigue.  It  may  never  be  possible,  in  fact,  to  es- 
tablish any  definite  standard  of  physical  and  mental  labor  for 
either  adults  or  children  until  scientific  measures  for  fatigue  and 
reaction  from  fatigue  have  been  established.  "Young  per- 
sons," says  Dr.  Hayhurst,  of  Ohio,  "particularly  those  under 
eighteen  years  of  age,  are  permanently  and  more  seriously  dam- 
aged by  the  poisons  and  toxins  of  fatigue  than  are  those  of  ma- 
turity, because  the  functions  of  growth  and  development  are 
seriously  interfered  with  and  reserve  forces  are  so  dissipated 
that,  from  the  weakened  constitution,  liability  to  consumption 
and  heart  disease  is  great."  ^ 

1  Hayhurst,  E.  R.:     "Occupational  Diseases  and  Industrial  Hygiene.*?     Chicago  Tuber- 
culosis Institute  Bulletin,  Nov.  15,  1915. 


172 

The  war  and  its  accompanying  need  for  maximum  production 
of  munitions  has  attracted  considerable  attention  in  England  to 
the  subject  of  fatigue  and  its  relation  to  output.  Last  year  a 
report  was  issued  of  the  preliminary  results  of  some  experiments 
conducted  for  the  Home  Office  by  Dr.  Kent,  of  the  University 
of  Bristol/  with  a  view  to  discovering  "a  test  for  recognizing 
the  presence  and  a  gauge  for  estimating  the  degree  of  fatigue  as 
met  with  under  factory  conditions."  The  results  of  these  ex- 
periments indicate  that  in  the  power  of  recovery  from  fatigue 
is  to  be  found  an  index  of  the  general  condition  of  an  individual 
which  may  be  of  great  use,  but  the  most  promising  direct  tests 
of  fatigue  were  found  to  be  the  simple  measurements  of  acuity  of 
sight  and  hearing.  Dr.  Kent  considers  these  tests  of  great  im- 
portance because  of  their  simplicity  in  application  and  their  con- 
sistency in  results,  and  because  they  indicate  distinctly  fatigue 
of  only  moderate  severity. 

Recently,  however,  a  pamphlet  on  "Industrial  Fatigue  and 
its  Causes^"  has  been  issued  by  the  British  Health  of  Munition 
Workers  Committee  which  defines  fatigue  as  "the  sum  of  the  re- 
sults of  activity  which  show  themselves  in  diminished  capacity 
for  doing  work,"  and  which  concludes  that  the  true  sign  of  fatigue 
is  diminished  output.  But  it  may  be  questioned  whether,  in 
considering  the  effects  of  fatigue  on  children  and  their  develop- 
ment, diminished  output  would  be  an  adequate  test  even  in  an 
occupation  where  output  could  be  definitely  measured,  and  in 
an  occupation  involving  the  use  of  automatic  machinery  fatigue 
might  cause  a  serious  accident  long  before  any  diminished  output 
would  be  evident.  The  effects  of  fatigue  in  children  are  probably 
not  to  be  measured  within  any  definite  period,  but  only  within 
the  lifetime  of  the  individual.  According  to  Dr.  Treves,  of  Turin, 
speaking  at  the  International  Congress  of  Hygiene  and  Demog- 
raphy, in  1907,^  the  crux  of  the  whole  question  lies,  not  in  greater 
or  less  productiveness,  but  in  the  cost  to  the  worker  of  different 

*  Kent,  Albert  F.  S.:  "Interim  Report  on  an  Investigation  of  Industrial  Fatigue  by 
Physiological  Methods."     (Gt.  Brit.  Home  Dept.),  London,  1915. 

2  Gt.  Brit.  Ministry  of  Munitions:  Health  of  Munition  Workers  Committee,  "in- 
dustrial Fatigue  and  Its  Causes."     London,  1916.     (Memorandum  7.) 

»  Treves,  Zaccaria:  "Fatigue  as  a  Result  of  Occupation."  (In  14th  International 
Congress  of  Hygiene  and  Demography,  Berlin,  1907,  V.  2,  Sec.  4.) 


173 

units  of  production.  Says  Dr.  Treves,  "If  the  physical  cost  of 
the  long  hours  and  overstrain  which  characterize  unintelligent 
industrial  organization  were  directly  and  proportionately  evi- 
dent, both  in  the  sensation  of  fatigue  and  in  the  output  of  the 
industry,  individual  and  collective,  the  problem  of  fatigue,  as  a 
result  of  industrial  labor,  would,  in  my  opinion,  have  been  solved 
long  ago,  instead  of  being  obscured  by  the  illusory  profits  of  long 
hours  and  insufficient  wages." 

Any  standard  of  work  for  growing  children  should  obviously 
protect  them,  not  only  from  the  ordinary  occupational  hazards, 
but  also  from  labor  calculated  to  retard  their  physical  develop- 
ment or  to  cause  abnormalities  in  their  bodily  growth.  Short 
hours — perhaps  half-time  employment  and  half-time  schooling — 
and  adequate  provision  for  the  safety  and  sanitation  of  working 
places  where  children  are  employed  are,  of  course,  essential. 
The  age  limit  for  especially  hazardous  or  unhealthful  occupations 
should  be  as  high  as  experience  may  prove  desirable  even  if  all 
minors  are  excluded.  Young  persons  should  probably  not  be 
employed  at  all  in  occupations  where  poisonous  substances  are 
handled  or  given  off  for,  as  Dr.  Teleky^  points  out,  on  the  one  hand 
the  young  organism  is  peculiarly  sensitive  to  poisons,  and  on  the 
other  hand  the  care  and  strict  personal  prophylaxis  necessary 
cannot  be  expected  of  children.  The  age  limit  for  each  differ- 
ent occupation  should  be  set  so  high  that  on  reaching  it  every 
normal  child  may  be  expected  to  work  without  injury  in  that 
particular  occupation.  But  every  child — every  minor — at  work 
should  be  examined  periodically  to  determine  whether  he  is  being 
injured  or  his  growth  is  being  interfered  with  by  what  he  is  doing. 
This  may  seem  a  high  standard,  but  it  is  a  necessary  standard 
for  the  efficiency  of  the  race,  either  in  war  or  in  peace. 

In  conclusion,  I  should  like  to  urge  upon  the  medical  profession, 
not  only  the  political  and  social  importance  of  the  establishment 
of  standards  which  will  make  possible  the  intelligent  enforcement 
of  already  existing  child  labor  laws,  but  also  the  need  for  such 
scientific  investigations  of  the  effects  of  different  occupations  on 
the  body  during  its  formative  period  as  will  furnish  an  authorita- 
1  Op.  cit. 


174 

tive  basis  for  further  legislation.  As  Professor  Loriga  states: 
"Only  an  individual  who  has  had  a  sane  and  normal  development 
can  acquire,  when  grown,  fulness  and  equilibrium  of  all  his  facul- 
ties and  be  able  to  perform  his  work  with  the  greatest  possible 
physical  strength  and  mental  efficiency.  In  order,  therefore, 
to  conserve  and  increase  the  most  valuable  capital  of  society — 
the  force  and  health  of  mankind — it  is  our  imperative  duty  to 
adopt  such  measures  as  will  prevent  the  impoverishment  of  child 
life."  .Yet  only  by  exact  observations  and  measurements  can  it 
be  conclusively  demonstrated  whether  or  not  in  this  country,  as 
in  Europe,  early  labor  endangers  the  physical  development  of 
children  and  causes  young  people  to  grow  up  stunted  or  malformed 
who  under  other  conditions  would  be  healthy,  vigorous  and  well 
built. 

DISCUSSION. 

Dr.  Charles  Bernstein,  Rome,  N.  Y. : 

The  Royal  Commission  in  England  found  that  as  a  result  of  the  mother 
working  during  gestation  the  children  were  much  smaller  and  of  less  weight 
than  those  of  mothers  living  under  different  conditions.  In  the  matter  of 
child  labor  I  often  wonder  what  is  going  to  happen  to  the  child  from  i6  t^ 
1 8  years  of  age  if  he  is  to  be  prevented  from  working,  and  whether  as  a  result 
of  bad  habits  formed  thru  lack  of  occupation  his  condition  will  not  be  much 
worse  than  if  he  were  working. 

Mrs.  Florence  Kelley,  New  York  City: 

For  many  years  I  have  been  engaged,  as  a  member  of  the  National  Child 
Labor  Committee,  in  striving  to  get  standards  establisht  with  regard  to  child 
labor.  It  seems  a  deplorable  misfortune,  therefore,  when  the  official  critic 
of  a  paper  rich  in  facts  and  ideas,  and  written  with  care  ahd  caution,  sleeps 
thru  the  reading  and  then  imputes  to  it  that  which  is  not  in  it.  There  is  no 
suggestion  in  Dr.  Sumner's  paper  of  prohibiting  work  for  young  people  be- 
tween 1 6  and  i8.  No  advocate  of  restricting  child  labor  in  this  country 
proposes  anything  so  absurd  as  that.  We  have  unfortunately  no  medical 
study  of  the  effect  of  work  upon  the  children.  That  is  a  need  very  greatly 
felt  by  the  organizations  woich  are  seeking  legislation. 

Dr.  J.  L.  Heffron,  Syracuse: 

I  should  like  to  ask  Dr.  Sumner  whether  the  contention  which  I  have  heard 
is  correct  that  the  increasing  stature  of  the  young  women  and  young  men 
of  to-day  is  due  to  the  fact  that  the  boys  and  girls  of  the  middle  and  upper 
classes  are  overfed    and    underworked    diu-ing  the  period  of  development? 


175 

In  establishing  a  standard  of  development  I  do  not  think  that  height  alone 
is  to  be  considered;  it  is  the  proportion  of  the  height  to  other  dimensions  of 
the  body  that  is  to  be  considered.  The  children  in  this  country  of  the  better 
classes  are  relatively  larger  than  the  children  of  the  same  classes  of  other 
countries. 

Dr.  Sumner,  closing: 

I  think  that  Mrs.  Kelley  answered  the  point  regarding  children  working 
between  the  ages  of  i6  and  i8.  I  do  not  mean  that  they  should  not  be  work- 
ing, but  that  they  should  not  do  work  which  would  stunt  their  physical  de- 
velopment. 


WOMEN  AS  WAGE-EARNERS. 

By  Mrs.  FlorbncB  Kellby,  General  Secretary,  National  Consumers'  League,  New 
York  City. 

In  two  fields  the  National  Consumers*  League  has  long  been 
activ,  in  the  effort  to  shorten,  by  laws  and  court  decisions,  the 
working  hours  of  women  wage-earners,  and  in  modifying  by 
minimum  wage  legislation  the  pay  that  they  get. 

Recently  a  new  problem  has  arisen,  that  of  compulsory  sick- 
ness insurance  as  it  affects  women. 

The  importance  of  laws  shortening  women's  working  day  grows 
by  leaps  and  bounds  with  the  growth  of  their  numbers  and  the 
speed  and  strain  involved  in  their  work. 

Recently  the  number  of  wage-earning  married  women  seems  to 
have  been  suddenly  increast.  Altho  all  statistics  on  this  sub- 
ject more  recent  than  the  United  States  Census  of  1880  are  mere 
guesswork,  those  of  us  who  have  long  been  living  in  the  industrial 
pit  know  that  married  women  are  more  numerous  in  certain 
industries  and  certain  nationalities.  One  markt  exception  is 
the  Russian  Jewish  colonies  where  the  mothers  stay  at  home  with 
the  children.  Incidentally  the  local  health  figures  seem  every- 
where to  show  an  exceptionally  low  infant  mortality  rate  among 
Russian  Jewish  families. 

Among  other  nationalities,  the  Italians,  Bohemians  and  Poles, 
for  instance,  there  is  notoriously  rapid  growth  of  married  women 
in  laundries,  canneries,  cigar  and  tobacco  factories  and  in  the 
needle  trades.  In  many  of  these  places  women  have  to  make 
great  physical  exertion. 

These  facts  enhance  the  importance  of  the  decision  of  the 
Supreme  Court  of  the  United  States  sustaining  as  valid  the 
California  eight-hours  law  for  women  employed  in  all  occupations 
except  domestic  service,  nursing  the  sick  as  graduate  nurses,  and 
horticulture,  viticultmre,  and  agriculture. 

Four  states  now  have  the  eight-hours  day  for  women,  upheld 
by  this  decision:  Arizona,  California,  Colorado,  and  Wash- 
ington. 


177 

Five  other  states  have  establisht  by  law  a  period  of  rest  at 
night  for  women:  Massachusetts,  New  York,  Pennsylvania, 
Indiana  and  Nebraska. 

Connecticut  provides  that  women  shall  not  work  in  factories 
after  lo  p.m.,  but  does  not  prescribe  when  they  may  begin  in 
the  morning.  Since  the  war  began  and  contracts  poured  in, 
therefore,  the  following  schedule  has  been  in  force  in  a  great 
munitions  works  in  New  Haven :  The  day  shift  begins  at  7  a.m. 
and  ends  at  6  p.m.,  with  an  hour  off  at  noon.  The  evening  shift 
works  from  6  p.m.  to  10  p.m.  In  compliance  with  the  law  it 
then  stops.  Two  hours  are  spent  in  a  dance  hall,  eating  late 
supper  and  dancing.  At  one  minute  past  midnight  it  is  the 
next  day,  and  work  is  resumed  and  continues  until  6  a.m.,  the 
evening  shift  thus  completing  its  legal  working  period  of  ten 
hours  interrupted  from  10  p.  m.  to  midnight. 

Tuberculosis  nurses  and  charity  workers  in  New  Haven  re- 
port much  illness  among  mothers  who  work  at  night  and  take  care 
of  their  homes  and  children  by  day. 

All  efforts  to  amend  the  Connecticut  law  to  correspond  with 
the  California  decision,  or  even  with  the  less  advanced  statutes 
of  the  eastern  neighbors  of  Connecticut  where  night  work  is 
limited,  have  failed. 

The  Consumers*  League  defends  statutes  shortening  the  work- 
ing hours  of  women,  when  they  are  attackt  as  unconstitutional. 
In  numerous  elaborate  briefs  it  has  placed  before  the  United  States 
Supreme  Court  the  facts  relating  to  fatigue  and  disease.  It  is  a 
singular  circumstance  that  we  are  only  now  beginning  to  get 
from  the  American  medical  profession  any  substantial  contribu- 
tions of  facts  available  for  these  briefs. 

Of  equal  importance  with  overwork  in  relation  to  disease  is 
underpay.  Mr.  Brandeis,  now  Justice  Brandeis  of  the  Supreme 
Court  of  the  United  States,  giving  his  services  as  counsel  for 
the  Consumers'  League,  therefore,  defended  before  the  Supreme 
Court  of  the  United  States  on  December  17,  19 14,  the  Oregon 
minimum  wage  law,  being  invited  by  Attorney-General  Brown, 
of  Oregon.  The  Oregon  Industrial  Welfare  Commission  had 
prescribed   $8.64   as   the   minimum    weekly  wage  of  an  adult 


178 

woman  employed  in  a  paper  box  factory  in  the  City  of  Portland. 
No  decision  has  been  reacht,  and  a  rehearing  has  been  ordered 
after  the  election. 

If  the  Com!  holds  the  Oregon  law  unconstitutional,  the  Con- 
sumers' League  will  be  confronted  by  the  heartbreaking  task  of 
amending  the  Constitution  and  changing  the  powers  of  the  Court, 
for  a  democratic  industrial  Republic  cannot  persist  in  which  grow- 
ing masses  of  wage-earners  are  unable  to  live  in  health  and  frugal 
decency  by  their  daily  work. 

I  regret  very  much  not  to  have  heard  the  discussion  upon  in- 
dustrial insurance.  In  the  Eastern  States  it  is  proposed  to  re- 
quire compulsory  contributions  from  women  workers  to  the  in- 
surance fund.  This  is  a  form  of  new  taxation.  It  is  of  serious 
importance  where  thousands  of  women  are  living  at,  or  below, 
the  bare  level  of  vital  efficiency,  and  are  to  be  compelled  to  pay 
a  part  of  an  insufficient  wage  for  medical  treatment  of  ailments 
due  to  hunger. 

Before  making  compulsory  deductions,  a  living  wage  should 
first  be  assiured.  We  urge,  therefore,  that  insurance  be  made 
non-contributory  from  employes  who  get  less  than  $9 .  oo  a  week 
wages. 

We  contend,  also,  that  a  mandatory  provision  should  require 
the  presence  of  women  upon  all  boards,  commissions  and  com- 
mittees created  to  administer  funds  to  which  women  contribute. 

Finally,  we  protest  against  cash  bonus  payments  for  the  bene- 
fit of  men  who  send  their  child-bearing  wives  into  industry. 
There  is  at  present  no  ascertainable  answer  to  the  question, 
"Whose  child-bearing  wife  works  for  wages,  and  why  does  she 
work?" 

The  existence  of  such  provision  in  some  foreign  countries  does 
not  absolve  Americans  from  the  duty  of  thoro  enquiry  into  the 
American  facts.  To  legislate  without  enquiry  is  to  make  a  leap 
in  the  dark. 


HOUSING  REFORM  THROUGH  LEGISLATION. 

By  Mr.  Lawrence  VeilleR,  New  York,  Secretary,  National  Housing  Association. 

I  suppose  there  is  no  statement  we  hear  expressed  so  often 
these  days  as  that  there  is  too  much  legislation.  Legislation  is 
nothing  more  nor  less  than  public  sentiment  crystallized  in  writing. 
To  say  that  there  is  too  much  public  sentiment  is  rather  absurd. 

My  topic  is  "Housing  Reform  through  Legislation."  The 
housing  problem  some  of  us  are  just  beginning  to  be  conscious  of. 
It  is  a  problem  bound  up  with  civilization.  It  is  created  by  man 
and  therefore  can  be  cured  by  man. 

I  would  not  suggest  that  the  cure  of  bad  housing  conditions 
rests  solely  in  legislation,  but  probably  more  can  be  accomplished 
through  legislation  than  through  any  other  form  of  endeavor. 
Bad  housing  is  due  to  a  variety  of  causes.  As  modern  practi- 
tioners we  must,  of  course,  treat  causes  and  not  symptoms,  and 
when  we  come  to  treat  the  causes  of  bad  housing  conditions  the 
most  effective  remedy  will  be  found  to  be  through  the  medium 
of  legislation.  To  illustrate,  we  find  people  in  all  cities  living  in 
cellars,  underground  rooms  without  sunlight  or  ventilation. 
What  method  is  there  for  stopping  people  living  in  such  rooms? 
Education  has  not  proved  effective.  Suppose  we  find,  as  was 
found  in  New  York  some  years  ago,  350,000  windowless  rooms. 
Could  we  get  windows  into  those  dark  caves  by  telling  the  people 
they  ought  not  to  live  in  them,  or  by  saying  to  the  landlords 
that  they  ought  not  to  rent  them  ?  We  have  never  yet  been  able  to 
get  results  by  that  process.  The  only  effective  weapon  is  the 
club  of  legislation,  the  strong  arm  of  the  law.  The  methods  we 
are  employing  in  housing  reform  are  the  same  as  the  methods 
that  are  employed  in  the  matter  of  securing  a  proper  milk  supply. 
No  one  would  think  of  controlling  that  vitally  important  ques- 
tion by  building  a  model  dairy.  Instead  they  would  pass  laws 
to  prohibit  the  sale  of  bad  milk.  The  same  principle  applies 
to  housing  which  is  as  much  a  commodity  as  anything  else.  We 
have  found  that  the  largest  returns  in  results  come  through 


i8o 

wise  legislation  effectively  enforced.  There  is  an  unfortunate 
tendency  among  Americans  to  think  that  with  a  law  once  passed 
we  have  solved  or  cured  a  condition.  At  the  best  the  passing 
of  a  law  may  be  said  to  represent  the  aspirations  of  the  people. 
A  poor  law  well  enforced  is  better  than  a  good  law  badly  enforced. 

No  one  admires  the  work  of  the  health  officers  of  the  country 
more  than  I  do,  but  health  work  in  the  United  States  is  still  in 
its  infancy.  Many  of  the  health  officers  do  not  even  know  the 
conditions  in  their  own  cities.  In  a  recent  eJBFort  to  find  the  num- 
ber of  privy  vaults,  etc.,  I  felt  I  could  get  the  information  from 
the  health  officers  of  different  municipalities.  I  found,  how- 
ever, there  was  no  list  of  such  officers  in  existence  anywhere. 

In  all  our  cities  we  see  the  same  bad  housing  conditions;  it  is 
only  a  matter  of  degree.  The  methods  of  remedying  the  evils 
come  down  primarily  to  legislative  effort.  We  get  99  per  cent, 
of  result  through  legislative  effort  compared  with  i  per  cent, 
through  other  forms  of  effort.  I  do  not  mean  to  say  that  there 
are  not  other  efforts  that  are  most  profitable.  We  should  do 
everything  that  will  yield  results — if  the  single  tax  or  suffrage 
will  get  us  results,  let  us  by  all  means  use  them — let  us  do  every- 
thing that  will  give  results,  but  experience  shows  in  the  long  run 
that  we  get  the  greatest  degree  of  results  through  laws. 

Some  of  the  worst  housing  conditions  can  be  overcome  only  by 
education,  especially  education  of  the  people  who  live  in  the  houses. 
No  one  needs  education  perhaps  more  than  the  average  landlord, 
and  the  architect  as  well.  Many  a  woman  breaks  her  back  bend- 
ing over  a  low  sink  because  no  one  has  sense  enough  to  make  it 
higher.  The  matter  of  the  right  kind  of  houses  rather  than  the 
building  of  tenements  is  worthy  of  much  study.  In  some  places 
tenements  are  the  only  things  possible;  in  other  places  the  small 
house  is  perfectly  feasible.  The  detached  house  allowing  the 
entrance  of  fresh  air  should  be  built  rather  than  the  house  in 
rows,  where  this  is  possible.  Such  houses  perhaps  are  not  feasi- 
ble for  the  man  who  gets  from  nine  to  fifteen  dollars  a  week,  but 
this  touches  upon  other  aspects  of  the  housing  problem.  Legis- 
lation still  remains  the  way  in  which  we  shall  get  the  larger  re- 
turns, the  99  per  cent,  of  results  instead  of  the  i  per  cent.     Every 


i8i 

community  having  slums  must  start  with  the  fundamental  law 
that  houses  unfit  for  human  beings  shall  not  be  allowed  to  exist. 
When,  through  legislation,  a  city  is  rid  of  its  worst  conditions,  its 
people  then  may  well  turn  to  other  interesting  and  profitable 
forms  of  endeavor. 

DISCUSSION. 

Dr.  John  B.  Andrews,  New  York  City: 

I  feel  that  we  may  all  take  off  our  hats  to  Mrs.  Kelley,  a  woman  who  has 
been  a  pioneer  in  social  work  and  who  has  always  had  the  courage  of  her 
convictions.  I  have  nothing  to  say  with  reference  to  the  hours  or  wages 
mentioned  in  Mrs.  Kelley's  paper,  but  will  use  the  two  or  three  minutes 
which  I  have  to  refer  to  a  few  points  concerning  the  health  insurance  aspect 
which  she  toucht  upon,  familiarly  known  as  maternity  insurance. 

Mrs.  Kelley  recognizes  the  existence  of  the  problem;  she  recognizes  that 
married  women  are  already  in  industry  to  a  very  large  number  and  that  that 
number  is  increasing  somewhat  rapidly.  We,  of  course,  know  that  there  are 
thousands  of  women  in  this  country  dying  each  year  in  childbirth  and  many 
more  thousands  of  little  children  dying  for  the  lack  of  care  at  the  time  of 
birth  and  shortly  thereafter.  We  also  know  that  the  governments  of  four 
states  in  this  country  have  already  recognized  this  problem  by  prohibiting 
by  law  the  industrial  employment  of  women  during  a  few  weeks  before  and 
after  childbirth.  At  the  very  time  when  a  woman  needs  assistance  the  most, 
we  at  present  say  she  shall  not  earn  her  usual  income,  and  in  this  respect 
we  are  different  from  all  other  countries  who  do  thru  social  insurance  look 
after  these  problems;  we  provide  nothing  for  her  as  a  matter  of  right  during 
that  time — no  medical,  obstetric  or  nursing  care,  yet  the  maternity  benefits 
are  universally  included  in  all  European  health  insurance  laws. 

Because  of  a  single  objection  bills  introduced  for  health  insurance  in  three 
states  in  1916  omitted  the  feature  of  maternity  benefit,  except  for  the  insured 
woman  herself.  The  bills  were  criticized  more  for  that  one  omission  than 
for  any  other  single  thing.  The  criticism  came,  so  far  as  I  know,  never  from 
"avaricious  husbands"  who  would  force  their  wives  into  the  factories  that 
they  might  profit,  but  almost  without  exception  from  women,  and  from  un- 
married women,  some  of  them  very  prominent  suffragists,  some  of  them 
very  prominent  socialists. 

Just  see  how  easy  it  is  to  safeguard  against  the  alleged  dangers  of  maternity 
benefit.  At  no  time  has  it  been  suggested  that  the  insured  woman  should 
not  be  in  the  fund  for  a  period  of  at  least  six  months  before  she  is  entitled  to 
draw  any  benefits.  It  is  easy  for  people  to  come  up  with  definit  concrete 
proposals  to  increase  that  period.  It  is  also  easy  to  say  that  we  shall  place 
a  maximum  limit  upon  the  cash  benefit  which  can  be  paid.  When  you  re- 
call that  it  is  absolutely  necessary  that  a  woman  refrain  from  her  gainful 
employment  before  and  after  delivery  and  recall  that  the  premiums  must 


I82 

be  paid  in  and  know  that  the  maximum  benefit  depends  upon  that,  you 
reduce  the  opportunities  to  the  "avaricious  husband." 

As  to  the  unfairness  of  requiring  young  unmarried  women  to  pay  into  the 
fund,  I  beHeve  that  most  young  unmarried  women  will  be  mothers  later, 
and  if  we  recognize  the  principle  of  insurance  here  as  we  recognize  it  else- 
where we  shall  realize  that  these  young  people  going  into  the  insurance  plan 
will  reap  their  benefits  later.  I  already  pay  a  tax,  by  the  way,  for  schools 
in  the  City  of  New  York.  I  have  no  children  in  school,  but  I  have  a  little 
boy  nearly  a  year  old,  and  I  don't  object  to  paying  my  share  for  the  school 
system.  Neither  do  I  believe  that  the  most  of  us  object  to  paying  for  the 
care  of  the  women  and  children — the  babies — at  the  time  the  care  is  most 
needed.  It  seems  to  me  this  question  of  maternity  insurance  is  one  upon 
which  we  should  be  able  to  get  together  and  that  we  can  provide  for  ma- 
ternity benefits  in  America  as  they  are  provided  for  in  European  countries 
and  without  any  serious  difiQculty. 

The  President,  Dr.  George  A.  Hare,  Fresno,  Cal.: 

I  wish  to  thank  Mr.  Andrews  for  discussing  in  the  very  clear  manner  one 
of  those  questions  to  which  we  have  all  given  too  little  thought — the  care  of 
mothers  and  children. 

Mrs.  Kelley: 

I  shall  not  speak  upon  minimum  wage  legislation.  Social  insurance  legis- 
lation is  bound  to  come.  I  am  in  favor  of  it  in  principle  and  shall  be  in  prac- 
tice as  soon  as  the  laws  are  so  drawn  as  not  to  favor  the  sordid  husbands  at 
the  expense  of  family  life.  For  five  and  twenty  years  I  have  lived  at  the 
bottom  of  the  industrial  pit,  and  I  know  the  sordid  husbands  who  sit  in  the 
tenement  basements  gambling  while  their  wives  work  in  factories.  They 
may  do  this  because  they  have  been  workt  out  in  their  early  manhood,  I 
should  like  to  give  them  the  benefit  of  the  doubt.  But  it  is  a  clear  duty  to 
protest  against  all  bills  which  provide  for  gifts  to  sordid  husbands  out  of  the 
earnings  of  single  women,  many  of  whom  receive  wages  below  the  living 
level.  All  such  legislation  should  moreover  provide  for  representation  of 
women  upon  the  bodies  administering  insurance. 

Dr.  Hare: 

I  should  like  to  ask  Mrs.  Kelley  whether  she  is  opposed  to  the  legislation 
which  provides  that  a  woman  before  and  after  confinement  may  not  work 
for  a  definit  time  and  that  for  this  time  there  shall  be  an  insurance?  If  so, 
has  she  any  method  of  solution  of  the  difficult  questions  involved  in  the  ob- 
jection she  has  raised. 

Mrs.  Kelley  (replying  to  Dr.  Hare) : 

The  first  thing  we  need  in  this  country  is  to  ascertain  whose  wife  works 
for  wages.  We  do  not  know  how  many  wage-earning  child-bearing  wives 
there  are,  or  what  their  husbands  are  doing. 


MEDICINE  AND  THE  INDUSTRIES. 

By  George  M.  Price,  M.D.,  New  York,  Director,  Joint  Board  of  Sanitary  Control. 

Medicine  is  a  complex  science.  Its  subject  is  the  human 
living  body.  Its  object  is  to  treat  the  iUs  which  the  body  is  heir 
to.  Its  purpose  is  to  cure  and  also  to  prevent  disease.  Its  ideal 
is  to  preserv  the  health  and  to  prolong  the  life  of  man. 

Man  is  a  social  being — a  unit  of  a  big  social  organism.  His 
bodily  ills  are  often  caused  by  his  physical  environment.  The 
spread  of  disease  is  favored  by  close  social  contact.  His  health 
and  length  of  life  are  profoundly  influenced  by  the  economic, 
social,  intellectual  and  moral  progress  of  society. 

Medicine  is  therefore  also  a  social  science.  In  its  study  of  the 
etiology  of  disease  it  must  take  into  consideration  all  the  many 
and  various  factors  influencing  human  health  and  length  of  life. 
In  the  study  of  means  of  healing  it  must  take  cognizance  of  all 
the  facts  which  bear  upon  the  predisposition  of  the  body  to 
disease,  the  increase  of  its  power  of  resistance  and  the  curativ 
effects  of  the  environmental  and  social  conditions.  In  the  pursuit 
of  its  ideal  to  prolong  the  span  of  life,  medical  men  must  become 
the  priests  of  prophylaxis,  the  teachers  and  preachers  of  indi- 
vidual, municipal,  public  and  social  hygiene. 

Ours  is  an  industrial  age — an  industrial  form  of  society.  The 
economic  industrial  factor — ^the  method  of  industrial  production — 
is  the  foundation  upon  which  the  whole  superstructure  of  intellec- 
tual, moral  and  social  development  rests  and  is  based.  The  in- 
dustrial population  is  the  predominating  part  of  society.  The 
queens  and  the  drones  are  but  a  small  minority  of  the  human 
bee-hive. 

Hence  the  interdependence  of  disease,  health  and  life  with 
industry,  industrial  conditions  and  industrial  population.  Hence 
the  close  interrelation  between  medicine  and  the  industries. 


1 84 

I. 

Modem  industrial  society  is  scarcely  one  hundred  and  fifty 
years  old.  It  has  succeeded  the  ancient  and  medieval  forms  of 
society  based  upon  slavery  and  the  feudal  systems. 

From  the  dawn  of  human  history  and  the  very  beginning  of 
the  science  of  medicine,  the  influence  of  work  upon  man  was 
recognized  by  physicians. 

Hippocrates  knew  that  "there  are  many  handicrafts  and  arts 
which  cause  those  who  exercise  them  certain  pains  and  plagues" 
and  speaks  of  the  specific  diseases  of  miners  and  burden  carriers, 
of  gardeners,  riders,  etc. 

Plato  considered  philosophy  unfit  for  those  "whose  bodies 
are  not  only  deformed  by  their  arts  and  handicrafts,  but  whose 
souls  are  also  in  like  manner  confused  and  crushed  by  their  lj£e 
of  labor." 

The  Romans  well  knew  the  effects  of  labor  upon  man.  Mart  al 
speaks  of  the  "blear-eyed  smith"  and  "lame  tailors."  Galien 
observed  the  diseases  of  certain  workers.  But  thruout  ancient 
times  all  work  was  peformed  by  slaves  whose  health  and  ^ives 
were  of  little  consideration,  and  medical  men  thot  little 
and  cared  less  about  occupational  diseases  and  the  cure  of  ills 
due  to  industry. 

Nor  was  the  condition  of  the  industrial  population  much 
better  during  the  middle  ages,  or  the  relation  of  medicine  to  in- 
dustry more  humane.  The  methods  of  production  changed  but 
the  slave  remained  a  serf.  Religious  intolerance  and  general 
ignorance  weighed  heavily  upon  the  industrial  population  and 
the  condition  of  workers  was  cared  for  but  little  by  the  medical 
man  of  that  time. 

Not  before  the  sixteenth  or  seventeenth  century  did  physicians 
begin  to  give  expression  to  the  knowledge  of  occupational  dis- 
eases and  to  a  desire  of  ameliorating  the  condition  of  the  workers. 

There  must  have  been  considerable  data  on  industrial  hygiene 
during  the  fifteenth  and  sixteenth  centuries  in  order  to  enable 
the  father  of  industrial  hygiene,  Ramazzini,  to  produce  his  epoch- 
making  work  on  the  "Diseases  of  Artisans" — a  work  based  upon 


i85 

rich  clinical  experience  and  a  deep  knowledge  and  insight  into 
industrial  activity  and  conditions. 

For  a  century  and  a  half  after  the  publication  of  Ramazzini's 
great  work,  very  little  was  done  in  the  field  of  industrial  hygiene, 
altho  here  and  there  may  be  found  the  names  of  physicians  who 
gave  some  attention  to  the  subject.  SuflSce  it  to  mention  but  a 
few  who  have  done  pioneer  service  in  this  field — such  as  Richard 
Mead  (Short  Discourse  Concerning  Pestilential  Contagion, 
etc.),  John  Pringle  (Diseases  of  the  Army),  James  Lind  (On 
Means  of  Preserving  the  Health  of  Seamen),  Gilbert  Blane 
(Observations  on  the  Diseases  of  Seamen),  C.  Turner  Thackrach 
(The  Effects  of  Various  Trades,  Professions,  etc.). 

But  it  is  only  since  the  middle  of  the  nineteenth  century  when 
industrial  hygiene  has  become  a  real  science,  thru  the  efforts  of 
Hirt,  Bhlenberg,  Albrecht,  Arlidge,  Layet,  Levy  and  the  more 
modem  representatives,  whose  names  are  familiar  to  everyone 
now. 

II. 

Three  elements  are  essential  for  industrial  production:  Raw 
materials,  machinery  and  human  workers.  The  greatest  progress 
of  the  industrial  age  has  been  made  in  the  invention  and  discovery 
of  means  of  production,  in  the  application  of  natural  forces  to 
industry  and  in  the  utilization  of  the  natural  resources  for  indus- 
trial uses.  This  has  been  attained  and  made  possible  by  the  prog- 
ress of  industrial  engineering  and  by  application  of  this  science 
to  industrial  pursuits. 

Altho  the  human  element  is  so  essential  to  industry,  no  such 
progress  has  been  made  in  the  development  of  human  resoturces, 
in  the  care  of  the  workers,  in  the  study  of  the  effects  of  arts  and 
crafts  upon  the  industrial  population,  of  the  prevention  of  occu- 
pational diseases  and  of  the  promotion  of  the  health  of  the  indus- 
trial element  of  the  population.  Industry  was  considered  as 
presenting  an  engineering  problem  alone.  The  great  medical 
problem  of  industry  was  entirely  neglected  and  the  science  of 
human  engineering  was  left  far  behind  that  of  technical  engineering. 

It  is  only  but  lately  that  the  importance  of  the  human  element 
in  industry  has  been  recognized,  that  the  relation  of  medicine  to 


i86 

industry  has  become  much  closer  and  the  physician  has  been 
called  upon  to  take  his  place  in  industrial  evolution  and  produc- 
tion. 

As  yet  industrial  hygiene  is  in  its  infancy  and  the  participation 
of  medicine  in  industry  but  at  the  very  beginning.  No  doubt, 
however,  exists  in  the  minds  of  all  who  have  knowledge  of  the  sub- 
ject that  great  changes  are  about  to  be  wrought  in  industrial 
methods,  and  the  paramount  importance  of  the  human  element, 
at  last  being  fully  recognized,  medicine  will  become  the  hand- 
maid of  industry  and  the  physician  an  important  part  of  industrial 
production. 

The  time  is  not  far  distant  when  every  industrial  plant  in  the 
country  will  engage  the  full-time  service  of  one  or  more  medical 
men  and  that  our  captains  of  industry  will  no  more  think  of  run- 
ning their  plants  without  a  medical  supervisor,  than  they  do  now 
without  a  technical  foreman. 

As  to  the  functions  of  the  industrial  physician,  these  are  bound 
to  develop  and  take  in  all  the  fases  of  indtXstrial  production  and 
the  care  of  the  health  and  hygiene  of  the  workers. 

The  functions  of  the  industrial  physician  will  be  to  supervise  (i) 
materials  of  production;  (2)  the  plant;  (3)  the  processes;  (4) 
the  conditions  of  work;  (5)  the  selection  of  workers;  (6)  the  medical 
care  of  the  workers  while  in  the  plant;  (7)  medical  care  of  the  work- 
ers and  their  families  outside  of  their  work;  and  (8)  educational 
activities  in  conjunction  with  the  medical  work. 

The  supervision  of  the  materials  of  production  is  necessary 
for  the  prevention  of  occupational  diseases  by  infection  and  the 
carrying  of  infectious  germs  in  some  of  the  materials,  also  in  a 
knowledge  of  the  toxic  nature  of  certain  materials  of  production 
and  their  effects  upon  workers  and  their  health,  and  possible 
substitution  by  inocuous  materials. 

The  supervision  of  the  plant  is  needed  for  the  proper  installa- 
tion of  all  safety  devices  and  to  insure  and  improv  the  ventila- 
tion, heating  and  sanitation  of  the  industrial  establishment. 

The  supervision  by  the  physician  of  the  industrial  processes 
must  be  a  part  of  his  duties  in  order  to  prevent  dangers  from 


187 

gases,  fumes  and  other  injurious  processes  adversely  affecting 
the  health  of  the  workers. 

The  supervision  of  the  conditions  under  which  work  is  carried 
on  becomes  necessary  in  order  to  regulate  the  temperature, 
humidity  and  other  conditions  under  which  the  work  is  being 
carried  on,  all  of  which  profoundly  affect  the  employes  of  a  plant. 

A  preliminary  medical  examination  in  the  selection  of  workers 
for  a  plant  is  imperativ  in  order  to  prevent  physically  unfit  work- 
ers to  take  up  tasks  for  which  they  are  not  fit. 

The  proper  care  after  accidents,  first  aid,  periodic  examinations 
and  dispensary  clinics  within  the  shops  are  needed  to  preserv 
the  health  of  the  workers,  to  prevent  disease  and  to  keep  them 
in  a  sound  condition. 

The  care  of  the  health  of  the  workers  and  their  families  outside 
of  the  industrial  plant  in  which  they  work  is  a  necessary  adjunct 
to  the  work  within  the  plant,  because  it  avails  little  to  take  care 
of  the  health  and  lives  of  workers  during  the  eight  or  ten  hours 
they  are  within  the  industrial  plant,  while  totally  neglecting  the 
same  during  the  sixteen  or  fourteen  hours  that  they  are  outside 
of  their  shop. 

Finally,  educational  activities  by  industrial  physicians  are 
factors  in  the  improvement  of  the  health  of  the  workers  and 
consist  in  teaching  personal  and  industrial  hygiene  and  inculcating 
the  proper  habits  of  health  and  life  among  the  industrial  popula- 
tion and  their  families. 

III. 

It  is  thus  apparent  that  the  relation  of  medicine  to  industries 
is  very  important  and  is  bound  to  become  more  important  as  in- 
dustry calls  in  the  physician  and  makes  him  an  integral  part 
of  its  organization.  It  is  time  therefore  for  the  medical  profession 
to  prepare  for  the  coming  events  and  to  educate  its  members  in 
the  new  specialty  of  industrial  hygiene.  It  is  about  time  for  our 
colleges  and  medical  institutions  to  create  and  open  new  depart- 
ments where  occupational  diseases  and  industrial  hygiene  should 
be  taught  and  expounded,  and  where  students  may  take  under- 


and  post-graduate  courses  fitting  them  for  the  important  tasks 
before  them. 

In  a  time  when  the  whole  country  is  being  agitated  and  aroused 
for  mihtary  preparedness  and  increase  in  our  supply  of  means  and 
devices  for  human  destruction,  the  medical  profession,  ever  on 
the  side  of  charity  and  humanity,  should  be  in  the  fore  in  the  cause 
of  medical  industrial  preparedness  and  of  progress  in  the  welfare 
and  health  of  the  industrial  population. 


THE  PHYSICALLY  DEFECTIV. 

By  Edward  O.  Otis,  M.D.,  Boston. 

Whether  any  of  us  are  mentally  perfect  is  a  question,  for  as 
Tuke,  the  great  authority  on  mental  diseases,  remarks,  it  is  to 
be  assumed  that  the  deity  is  sane  but  whether  anybody  else  is, 
is  a  debatable  question.  At  all  events,  most  of  us  have  some 
kind  of  a  mental  bias.  Morally,  we  confess  that  we  are  all  "miser- 
able sinners;"  physically,  we  are  no  less  imperfect.  "There  is 
always  somewhere  a  weakest  spot."  However,  that  "weakest 
spot"  does  not,  with  the  majority  of  men,  incapacitate  them  for 
a  man's  career  in  the  world.  It  is  only  some  markt  and  glaring 
physical  deviation  from  what  we  call  the  normal  that  places  one 
in  the  category  of  the  physically  defectiv,  and  this  class  is  what 
we  have  to  consider. 

Mind  and  will  always  triumph  over  matter,  and  when  the 
will-power  is  intelligently  directed  and  grimly  determined,  it 
will  make  a  defectiv  body  do  its  bidding.  Illustrations  of  this 
are  innumerable,  and  all  of  us  can  doubtless  recall  examples  in 
our  own  experience  of  success  attained  in  spite  of  physical  handi- 
caps. Henry  Fawcett  became  blind  thru  an  accident  at  the  be- 
ginning of  his  career,  yet  later  he  became  professor  of  political 
economy  at  Cambridge  University,  a  writer  upon  the  subject, 
a  member  of  Parliament  and  Postmaster-General  of  England. 
Huber,  the  blind  naturalist,  contributed  to  entomologic  science 
some  new  observations  upon  the  habits  of  the  bees.  It  was  Mil- 
ton's blindness  which  gave  us  that  matchless  poem,  so  sad  and 
yet  so  triumphant: 

When  I  consider  how  my  light  is  spent 
Ere  half  my  days,  in  this  dark,  world  and  wide. 
And  that  one  talent  which  is  death  to  hide 
Lodged  with  me  useless. 

The  remarkable  development  of  Helen  Kellar  is  familiar  to  us 
all.  One  of  our  own  United  States  Senators  is  blind,  and  an 
eminent  member  of  our  own  profession,  who  has  added  most  to 


medical  literature,  has  suffered  from  the  same  misfortune  since 
youth.  Even  our  friend  Silas  Wregg,  with  the  handicap  of  his 
wooden  leg,  made  the  most  of  his  opportunity  and  won  temporary 
distinction  as  an  educator  of  the  credulous  Mr.  Boffin. 

The  men  and  women,  however,  who  have  achieved  markt  dis- 
tinction in  spite  of  acquired  or  congenital  physical  defects  are  the 
exception.  Besides  the  will  to  succeed  and  an  exceptional  mind, 
they  usually  enjoyed  unusual  opportunities  for  education.  Not 
so  with  the  great  mass  of  the  physically  defectiv.  Like  the  rest 
of  us,  they  are  of  mediocre  mental  inheritancte,  and  a  large  ma- 
jority are  without  means  of  education,  or  opportunity  of  develop- 
ment unless  some  assistance  is  rendered  them.  Such  are  the 
blind,  the  deaf  and  dumb,  the  crippled  and  deformed,  and  those 
suffering  from  various  other  physical  handicaps.  It  is  indeed 
bewildering,  as  well  as  depressing,  to  consider  the  vast  numbers 
of  this  kind  which  the  present  war  is  producing  at  wholesale. 

Granted  that  the  physically  defectiv  are  of  sound  mind,  there 
is  much  to  be  hoped  for  in  their  care  and  education,  as  experience 
has  shown;  the  "lame  man  may  not  leap  as  an  hart,  or  the  eyes 
of  the  blind  be  opened,  or  the  ears  of  the  deaf  be  unstopped, 
or  the  tongue  of  the  dumb  sing,"  but  many,  perhaps  the  most, 
can  be  expected  to  become  self-supporting  or  more;  they  can  be 
trained  to  employ  the  faculties  that  remain  to  the  best  advan- 
tage and  thus  discount  their  handicaps. 

The  legitimate  duty  of  the  state  is  to  provide  for  the  welfare 
of  its  people — all  its  people;  and  each  state  must  decide  in  what 
way  and  how  far  it  will  and  can  do  this.  Two  fundamental  ob- 
jects, however,  are  obviously  the  duty  of  every  well-ordered 
state:  First,  to  protect  its  citizens  from  palpable  injurious  in- 
fluences, such,  for  example,  as  contagious  diseases,  impure  food 
and  drink,  unwholesome  conditions  in  factory  and  workshop, 
exploitation  of  child  labor,  etc.;  hence  the  free  distribution  of 
diphtheria  antitoxin,  compulsory  vaccination,  milk  and  food  in- 
spection, the  notification  of  contagious  diseases,  hospitals  for 
consumptives,  etc.  Second,  to  afford  its  citizens  an  opportunity 
for  development,  a  chance  to  realize  that  "freedom,  equality, 
and  pursuit  of  happiness"  which  is  declared  to  be  the  birthright 


191 

of  us  all  in  this  country;  hence  the  public  schools  and  libraries, 
and  other  public  educativ  measures.  Furthermore,  the  public 
has,  to  a  greater  or  less  degree,  taken  upon  itself  the  duty  of 
caring  for  many  of  its  unfortunates  in  mind  or  body,  both  for 
their  own  good  and  also  to  prevent  them  from  being  a  source  of 
injury  to  others,  or  from  becoming  dependents;  hence  the  public 
hospitals  and  insane  asylums,  institutions  for  the  feeble-minded, 
comsunptiv  sanatoria,  reformatories  for  the  criminal  class,  schools 
or  institutions  for  the  crippled  and  deformed,  the  blind  and  the 
deaf  and  dumb. 

It  is  of  the  three  latter  classes  of  physical  infirmities  that  I 
wish  especially  to  speak,  namely:  (a)  the  crippled  and  deformed; 
(b)  the  blind;  (c)  and  the  deaf  and  dumb,  for  they  constitute 
the  major  part  of  those  whom  we  include  under  the  physically 
defectiv  and  for  whom  legislation  has  done  much,  particularly 
for  the  blind  and  the  deaf  and  dumb.  For  the  crippled  and  de- 
formed the  states  do  not  appear  to  have  made  equal  or  adequate 
provision,  altho  this  class  probably  largely  outnumbers  the  other 
two  classes.  "It  may  be  stated  in  general,"  says  the  Secretary 
of  the  State  Board  of  Charities  of  Massachusetts,  "that  the  pub- 
lic care  of  crippled  and  deformed  children  who  are  not  necessarily 
public  dependents,  is  the  rare  exception  rather  than  the  rule  in 
social  development."  We  still  see,  all  too  frequently,  the  maimed 
or  crippled  man  selling  lead  pencils  or  shoestrings  on  the  street 
corner,  who,  with  an  industrial  education,  might  be  setting  type 
or  cane-seating  chairs  and  earning  a  steady  and  not  a  half -begging 
precarious  income.  How  much  more  inspiring  is  it  to  undertake 
the  education  of  a  crippled  child  with  a  sound  mind  than  to  expend 
the  same  amount  upon  a  feeble-minded  one  who  can  never  be 
anything  but  a  burden  upon  the  community !  How  many  crippled 
children  and  adults  there  are  in  the  United  States  no  one  knows, 
for,  unfortunately,  no  census  of  them  has  ever  been  taken.  Dr. 
Orr,  of  the  Nebraska  Orthopoedic  Hospital,  estimates  the  number 
as  259,000.  Prof.  Lange,  quoted  by  Miss  Reeves,^  stated  in  19 10 
that  the  number  of  crippled  children  under  fifteen  years  of  age  in 

1  "Care  and  Education  of  Crippled  Children  in  the  United  States,"  by  Edith  Reeves, 
Russell  Sage  Foundation,  N.  Y.,  Survey  Associates,  etc.,   1914. 


192 

Germany  was  98,263.  One  hardly  dares  to  imagine  what  the 
number  of  crippled  and  maimed  adults  now  is  in  that  unhappy 
country  which  is  so  rapidly  producing  them.  If  the  number  of 
crippled  children  in  this  country,  says  Miss  Reeves,  bore  the  same 
proportion  of  the  general  population  as  in  Germany,  there  would 
be  about  133,000  crippled  children  under  fourteen  years  of  age, 
and  at  present  only  4,901  are  cared  for  in  the  37  existing  institu- 
tions for  them,  public  and  private. 

It  is  evident,  then,  that  a  not  inconsiderable  number  of  such 
children,  indeed  the  greater  number,  are  growing  up  illiterate 
and  without  training  owing  to  their  inability  to  attend  the  com- 
mon schools.  It  would  appear  to  be  a  duty  as  well  as  an  economic 
measure  for  the  state  to  afford  these  defectives  a  common  school 
and  industrial  education  and  thus  render  them  self-supporting 
members  of  society  instead  of  a  burden  upon  it.  There  are  only 
five  institutions  for  crippled  and  deformed  children  maintained 
entirely  by  state  appropriations:  one  each  in  Massachusetts, 
New  York,  Nebraska  and  two  in  Minnesota.  Some  of  the  other 
similar  institutions  receive  public  aid  but  are  controlled  and  ad- 
ministered by  private  boards.  The  "Massachusetts  Hospital 
School"  is  the  largest  and  most  elaborate  of  its  kind  in  America 
and  has  a  capacity  for  250  children  from  five  to  fifteen  years  of 
age  who  are  "mentally  competent  to  attend  the  public  schools." 
It  was  establisht  in  1907  by  a  state  appropriation  of  $300,000 
and  the  annual  maintenance  expense  at  the  present  time  is  $80,000. 
Besides  indicated  surgical  treatment,  the  children  are  given 
a  common  school  and  industrial  training.  As  stated  in  the  act 
establishing  the  school,  "the  purpose  (of  which)  shall  be  the 
education  and  care  of  the  crippled  and  deformed  children  of  the 
Commonwealth."  Industrial  training  is  given  in  household 
arts,  sewing,  and  handicrafts,  such  as  basketry,  printing,  tailor- 
ing, cobbling,  carpentry,  etc.  "The  results  achieved,"  says  Miss 
Reeves,  "thru  vocational  training  evolved  from  the  daily  life 
of  a  large  institution  are  most  strikingly  seen  here  and  at  the 
Widener  Memorial  School."  This  latter,  the  Widener  School, 
is  a  residential  institution  and  is  probably  the  most  perfect  one 


193 

of  its  kind  in  the  world,  both  in  the  perfection  of  its  plant  and 
in  its  large  endowment  of  four  million  dollars. 

The  New  York  Hospital  for  Ruptured  and  Crippled  is  a  similar 
institution  of  the  highest  development  and  efficiency,  at  which 
graded  school  work  and  vocational  training  are  afforded  for  the 
deformed  children,  the  City  Board  of  Education  paying  a  cer- 
tain sum  per  year  for  each  pupil. 

Besides  those  mentioned  above,  there  are  some  thirty  other 
institutions  of  a  more  or  less  analogous  character,  principally 
establisht  and  supported  by  private  charity.  Some  are  called 
hospitals,  some  asylum  homes,  some  convalescent  hospitals  or 
homes,  and  others  schools;  in  most  of  them  there  is  more  or  less 
educational  work  and  vocational  training. 

The  greatest  need.  Miss  Reeves  found  in  her  investigation, 
was  for  children  in  rural  communities,  and  the  only  institutions 
that  were  adequately  meeting  this  need  were  the  state  institutions 
of  Massachusetts,  New  York,  Minnesota  and  Nebraska. 

Besides  the  residential  institutions  for  the  crippled  and  de- 
formed children,  there  are  day  schools,  either  private  or  public; 
in  some  of  the  larger  cities  as  in  Chicago,  New  York,  Cleveland 
and  Detroit,  special  departments  or  classes  are  provided  in  the 
public  schools  for  such  children.  The  Boston  Industrial  School 
for  Crippled  and  Deformed  Children  is  a  notable  example  of  a 
highly  develop t  day  school  for  such  defectivs.  In  this  institu- 
tion, which  consists  of  one  large  building  for  general  use,  and  I 
refer  to  it  especially  as  it  is  in  my  own  city  and  I  am  familiar 
with  its  work,  there  is  a  primary  and  a  grammar  school  depart- 
ment similar  to  those  of  the  public  schools;  and  manual  training 
adapted  to  those  grades,  including  paper-folding,  clay  modeling, 
basket  making,  Sloyd,  cane-seating,  cobbling,  needlework,  cook- 
ing, typesetting,  and  printing.  Most  of  the  pupils  are  conveyed 
to  the  school  and  returned  to  their  homes  daily,  and  all  receive 
a  substantial  dinner  at  noon.  There  are  also  trade  classes  for 
those  over  fifteen  years  of  age,  and  as  soon  as  they  become  pro- 
ficient these  workers  receive  pay.  Connected  with  this  school 
is  a  modem  outdoor  school-room  for  those  suffering  from  deformi- 
ties of  a  tuberculous  origin.    Adjustable  desks  and  special  seats 


194 

are  provided,  cots  for  rest  periods  and  special  gymnastic  training 
are  given.  A  nurse  is  constantly  in  attendance  who  also  visits 
the  children  at  their  homes.  There  is  also  medical,  surgical  and 
dental  supervision  and  care. 

It  is  evident  that  state  legislation  needs  to  do  far  more  for  this 
hopeful  class  of  young  defectives  than  yet  has  been  done,  for  as 
has  been  noted  above  only  about  5,000  are  at  present  cared  for. 
Apparently  the  crippled  and  deformed  do  not  seem  to  make 
quite  the  appeal  to  one's  sympathies  as  do  the  blind  or  the  deaf 
and  dumb. 

For  the  class  of  indigent  adults  who  are  physically  defectiv 
for  such  diseases  as  rheumatism,  paralysis,  cardiac  disease,  syphilis 
and  other  incapacitating  conditions,  the  state  almshouses  or  work 
houses  are  the  common  public  provision,  and  all  states  provide 
such  accommodations,  some  better,  some  w^orse.  Private  charity 
also  supplements  the  state  provisions  by  various  homes  and  hospi- 
tals, such,  for  example,  as  the  Robert  Brigham  Hospital  for  In- 
curables in  Boston  with  an  endowment  of  several  million  dollars. 

The  loss  of  one  of  the  senses,  like  that  of  sight  or  hearing,  seems 
such  an  incomparably  greater  misfortune  than  to  be  crippled  or 
deformed,  that  one's  sympathy  and  pity  are  more  strongly  aroused 
towards  this  unfortunate  class.  To  be  forever  shut  out  from  the 
sight  of  all  the  objects  of  beauty  and  interest  in  the  world,  or  never 
to  hear  the  sound  of  a  friend's  voice  or  the  Largo  of  a  Handel 
is  indeed  an  appealing  misfortune,  and  hence  it  is  that  the  public 
early  exprest  its  sympathy  in  a  practical  form  and  began  to  make 
provision  for  the  education  and  training  of  the  blind  and  the  deaf 
of  school  age,  so  that  at  the  present  time  every  state  either  has 
its  own  institutions  for  the  education  of  those  bereft  of  one  or  the 
other  of  these  two  senses,  or  else,  as  in  the  case  of  the  smaller 
or  sparsely  populated  states,  makes  arrangements  for  their  edu- 
cation at  public  expense  in  neighboring  states. 

As  the  census  report  of  19 10  upon  "Benevolent  Institutions" 
says:  "There  is  probably  no  one  class  of  persons  for  whose  educa- 
tion and  training  such  complete  provision  is  made  as  for  the 
blind  and  deaf."  At  the  twelfth  census,  an  investigation  con- 
ducted by  Dr.  Alexander  Graham  Bell  showed  that  there  was  a 


195 

minimum  of  64,763  blind  persons  in  the  United  States,  and  of 
these  somewhat  over  half  were  totally  blind  and  8,000  were  under 
twenty  years  of  age.  According  to  the  report  of  the  Commis- 
sioner of  Education  for  1908  there  were  forty  state  schools  for 
the  education  of  the  blind  with  4,340  pupils,  and  the  census  of 
1910  shows  4,720  in  such  institutions.  The  education  of  these 
children  is  not  regarded  as  a  charity  but  as  a  part  of  the  educa- 
tional system,  carried  on  at  public  expense.  In  1879  Congress 
appropriated  $250,000  as  a  perpetual  fund  for  the  purchase  of 
books  and  apparatus  for  the  different  state  schools.  Normal 
schools  for  the  blind  are  also  maintained  in  some  states.  The 
first  school  for  the  blind  establisht  in  this  country  was  a  private 
enterprise,  that  of  the  Perkins  Institute  in  Boston,  founded  in 
1829,  and  rendered  famous  by  its  two  great  directors,  Dr.  Samuel 
Howe  and  Dr.  Anagnos,  and  by  the  remarkable  work  of  the  former 
in  the  education  of  Laura  Bridgman,  who  was  deaf,  dumb  and 
blind.  With  infinit  patience  and  devotion  Dr.  Howe  succeeded 
in  unlocking  the  mind  of  this  poor  deaf  mute  until  she  became 
mentally  alert  and  developt  into  a  well-educated  woman.  Soon 
after  the  founding  of  the  Perkins  Institute,  those  at  New  York 
and  Philadelphia  were  establisht  in  1831  and  1833,  respectively, 
and  then  as  the  duty  of  the  public  towards  these  defectivs  began 
to  be  recognized  came  the  state  institutions,  which  now  exist 
in  nearly  every  state. 

The  education  given  is  at  first  similar  to  that  of  the  ordinary 
common  school,  accompanied  by  manual  training  and  gymnas- 
tics. Special  training  is  also  afforded  in  some  handicraft,  or  for 
some  professional  or  business  occupation,  according  to  the  talent 
and  ability  of  the  pupil.  Music  and  piano-forte  tuning  have 
been  found  peculiarly  adapted  to  the  blind,  and  some  have  at- 
tained eminence  in  the  latter,  as,  for  example,  John  Stanley, 
who  was  an  organist  at  the  age  of  eleven.  The  aim  in  the  educa- 
tion of  the  blind  is,  first,  to  establish  hope,  the  hope  that  in  spite 
of  their  grievous  handicap  they  can  attain  a  man's  standing  in 
the  world,  for  hope  stimulates  endeavor;  second,  to  give  them  a 
general  common  education;  and  third,  a  practical  or  technical 
education  so  that  they  may  become  self-supporting.     It  speaks 


196 

well  for  the  altruistic  spirit  as  well  as  for  the  economic  sagacity 
of  this  country  that  it  is  so  fully  and  liberally  accomplishing  this 
self-imposed  task.  Culture  and  humanity  are  not  necessarily 
close  companions,  as  is  vividly  illustrated  by  the  example  of  one 
of  the  belligerents  in  the  present  war.  We  still  seek  philosophy 
from  Plato  and  culture  from  ancient  Roman  literature,  but  it 
was  a  custom  both  of  the  Greeks  and  Romans  to  throw  their 
deaf  into  the  river  and  destroy  their  defectivs — a  rather  merciless 
eugenic  method  of  ensuring  a  sturdy  race.  The  deaf  were  re- 
garded as  being  in  the  same  class  as  idiots.  St.  Augustine  de- 
clared that  the  deaf  could  have  no  faith  since  "faith  comes  by 
hearing  only."  A  century  ago,  even,  the  deaf  were  practically 
outside  the  human  thought  and  activities,  and  for  a  long  time 
were  regarded  as  an  exceptional  class,  like  the  peculiar  silent  folk 
Rip  Van  Winkle  encountered  in  the  mountain  hollow.  Various 
legal  enactments  were  made  indicating  this  attitude  towards  them, 
such  as  exemption  from  poll  and  other  taxes;  forbidding  them 
from  making  wills,  unless  their  intention  was  declared  in  writing; 
the  appointment  of  guardians  for  them,  etc.  As  time  went  on, 
however,  and  civilization  advanced,  it  was  found  that  these  peo- 
ple of  silence  were  mentally  sound  and  by  education  could  be  de- 
velopt  into  rational  beings. 

At  the  beginning  of  the  last  century  schools  for  the  deaf  began 
to  be  founded  on  the  Continent  and  in  England,  and  in  18 16 
Gallaudet  establisht  the  first  school  for  the  deaf  in  America  at 
Hartford,  called  the  Connecticut  Asylum.  At  the  present  day 
liberal  state  provision  is  made  for  the  education  of  the  deaf  and 
the  deaf  and  dumb,  and  after  they  have  received  their  education 
they  are  regarded  as  are  any  other  members  of  society  and  are 
considered  able  to  look  after  themselves.  As  wage  earners 
they  compare  well  with  the  average  of  the  rest  of  the  population. 
According  to  the  Census  of  19 10  there  were  43,812  deaf  persons 
in  the  United  States,  90  per  cent,  of  whom  became  deaf  before 
the  twentieth  year  and  nearly  three-fourths  under  five  years  of 
age.  From  three-fifths  to  two-third  are  caused  by  accident  or 
disease,  mostly  from  the  latter,  of  which  scarlet  fever  and  menin- 
gitis are  the  most  frequent  causativ  factors. 


197 

In  every  state  except  New  Hampshire,  Nevada  and  Wyoming, 
there  are  pubHc  institutions  for  the  education  of  the  deaf,  and 
these  three  excepted  states,  on  account  of  their  small  population, 
make  provision  at  public  expense  for  their  deaf  in  other  state 
schools.  Some  states  have  more  than  one  such  school.  It  can 
be  said  that  every  deaf  child  in  the  United  States  under  twenty- 
one  years  of  age  is  now  given  the  opportunity  of  an  education  and 
afforded  maintenance  in  a  state  institution.  In  a  few  of  the 
Eastern  states  the  institutions  are  in  private  hands  but  receive 
state  assistance  and  are  subject  to  public  supervision.  In  ten 
states  there  are  dual  schools  for  the  deaf  and  blind. 

W.  H.  Addison,  of  the  Mosely  Commission  of  England,  who 
visited  this  country  in  1907,  testifies  that  "the  care  and  instruc- 
tion of  the  deaf  seems  everywhere  to  be  regarded  as  one  of  the 
first  duties  of  the  state  and  in  the  equipment  of  her  schools  for 
the  deaf  America  far  surpasses  Great  Britain." 

At  the  close  of  the  year  19 10  there  were  10,543  inmates  of  deaf 
and  dumb  institutions,  of  which  5,712  were  able  to  speak  and 
4,831  were  dumb.  Of  the  whole  number,  7,054  were  children 
and  of  these  4,172  were  able  to  speak. 

The  two  methods  of  teaching  the  deaf,  as  we  know,  are  the  sign 
and  the  oral  methods,  or  a  combination  of  the  two.  This  educa- 
tion is  not  cheap,  for  it  costs  the  state  eight  times  as  much  to  edu- 
cate its  deaf  children  as  its  hearing  ones  in  the  regular  public 
schools,  and  four  times  as  much  in  the  day  schools. 

Besides  the  state  institutional  schools  in  which  about  five-sixths 
of  the  deaf  children  are  educated,  there  are  day  schools  which  are 
a  part  of  the  public  school  system.  These  exist  principally  in 
the  large  cities,  as  in  New  York,  Chicago,  Boston,  and  elsewhere. 
One  of  the  first  schools  of  this  kind  was  the  Horace  Mann  School, 
establisht  in  Boston  in  1861.  There  are  now  in  all  sixty-five 
such  schools.  It  has  been  found,  however,  that  better  results 
are  obtained  in  the  institutional  or  boarding  schools,  where  the 
children  reside  continuously,  than  in  the  day  schools. 

In  addition  to  all  the  states  are  doing  for  the  deaf.  Congress 
estabHsht  at  Washington,  in  1857,  a  college  for  the  deaf  and  dumb, 


198 

now  united  with  the  Gallaudet  College  and  called  the  Columbia 
Institution.     This  is  wholly  supported  by  Congress. 

A  few  of  the  aged  and  infirm  deaf  are  found  in  the  almshouses, 
but  the  total  number  is  a  little  over  one  per  cent.,  thus  showing 
that  the  great  majority  of  the  deaf  form  a  self-supporting  part 
of  the  community  and  engage  in  almost  all  the  various  occupa- 
tions and  many  of  the  professions. 

Ancillary  to  the  problem  of  the  deaf  and  blind  is  the  medical 
examination  of  school  children,  by  means  of  which  these  distress- 
ing defects  in  sight  and  hearing  may  in  some  cases  at  least  be 
prevented,  for  by  the  early  detection  of  infantile  and  infectious 
diseases,  which  are  a  prolific  cause  of  deafness  and  blindness, 
and  by  timely  treatment,  such  ultimate  evils  may  be  avoided. 
In  Massachusetts,  the  law  requires  the  examination  of  the  eyes 
and  ears  of  the  school  children  in  all  cities  and  towns  of  the  state, 
the  State  Board  of  Education  furnishing  the  test. 

Another  great  class  which  may,  I  think,  be  included  under  the 
physically  defectivs  are  the  tuberculous,  altho,  of  course,  this 
incapacity  is  not  always  permanent,  and  the  aim  in  the  wide  pub- 
lic provision  made  for  them  is  not  only  treatment  and  care  but 
prevention.  Quite  every  state  has  establisht  one  or  more  sana- 
toria for  such  sufferers  and  maintains  them  at  public  expense. 
The  public  appropriation  for  this  purpose  last  year  (19 15)  was 
5^14,500,000,  and  of  this  sum  four  states.  New  York,  Pennsylvania, 
Illinois  and  Massachusetts,  contributed  over  eight  million  dol- 
lars. Besides  the  sanatoria  special  tuberculous  dispensaries 
are  maintained  by  some  states,  as  in  Pennsylvania.  In  Massa- 
chusetts all  cities  of  10,000  inhabitants  are  required  by  law  to 
establish  and  maintain  such  dispensaries.  Municipalities  in 
many  instances  maintain  similar  institutions  under  their  boards 
of  health,  and  likewise  open-air  schools  or  school-rooms  for  the 
children  with  evidence  of  latent  tuberculosis. 

Besides  sanatoria  for  supposedly  curable  cases  of  tuberculosis, 
consumptiv  hospitals  for  the  incurables  have  also  been  establisht 
in  some  states,  generally  thru  local  instrumentality,  but  with 
public  supervision  and  state  aid  in  maintenance.  In  Massa- 
chusetts the  law  requires  all  cities  to  establish  such  hospitals, 


199 

and  also  towns  when  requested  to  do  so  by  the  State  Board  of 
Health.  Municipalities  have  also  taxt  themselves  to  provide 
consumptiv  hospitals  for  their  indigent  incurables.  Chicago, 
by  the  mill  tax  upon  all  taxable  property  of  the  city,  has  erected  a 
great  institution  which  will  provide  for  nearly  a  thousand  patients. 
Boston  has  expended  over  a  million  dollars  upon  its  Consumptiv 
Hospital,  and  is  constantly  enlarging  it.  So  of  other  cities. 
It  is  now  proposed  that  by  an  act  of  Congress  a  special  division 
of  tuberculosis  should  be  establisht  in  the  United  States  Public 
Health  Service,  with  an  adequate  appropriation,  for  the  study 
and  investigation  of  the  tuberculosis  problem.  Thus  it  will  be 
seen  that  legislation  is  actively  engaged  thruout  the  country  in 
providing  for  its  physically  defectivs  thru  tuberculosis. 

Another  incapacitating  disease  which  in  recent  years  has  grown 
to  large  proportions  is  that  of  the  heart.  For  example,  in  New 
York  in  19 14  the  deaths  from  heart  disease  increast  from  74  to 
169  per  one  hundred  thousand,  and  other  cities  have  had  a  sim- 
ilar experience.  As  with  the  child  with  latent  tuberculosis,  so 
with  the  child  with  slight  or  latent  cardiac  disease.  Especial 
care  in  its  education  is  equally  necessary,  and  especial  vocational 
training,  so  that  it  may  learn  an  occupation  adapted  to  its  dam- 
aged heart.  The  wage-earner,  likewise,  with  cardiac  disease 
would  seem  to  deserv  the  same  consideration  as  the  tuberculous 
wage  earner.  It  would  appear,  therefore,  that  in  the  near  future 
some  public  recognition  and  provision  should  be  made  for  this 
class  of  defectivs,  if  they  continue  to  increase  in  the  future  as 
rapidly  as  in  the  past. 

DISCUSSION. 

Dr.  Charles  Bernstein,  Rome,  N.  Y.: 

Authorities  agree  that  there  are  approximately  32,000  feeble-minded, 
or  one  in  every  300  people,  thruout  the  State  of  New  York. 

Feeble-minded  now  Cared  For. 

The  number  of  feeble-minded  in  institutions  specially  designed  for  their 
care  are  as  follows: 


200 

In  the  Syracuse  State  Institution  for  Feeble-Mlnded  Children 550 

In  the  State  Custodial  Asylum  for  Feeble-Minded  Women 800 

In  the  Rome  State  Custodial  Asylum 1550 

In  the  Craig  Colony  for  Epileptics 1200 

In  the  Letchworth  Village 300 

New  York  City  Institutions  on  Randall's  Island 1600 

Total  in  public  institutions  for  feeble-minded 6000 

It  is  estimated  that  there  are  in  other  institutions  not  designed  for  their 
care  as  follows: 

In  state  prisons  and  jails  (estimate  15  per  cent.) 1500 

In  girls'  reformatories  (estimate  40  per  cent.) 400 

In  boys'  reformatories  (estimate  20  per  cent.) 900 

In  almshouses  (Report  of  State  Board  of  Charities) 1700 

In  state  hospitals 1 500 

Total 6000 

Out  of  an  establisht  feeble-minded  population  of  32,000,  about  6,000  are 
cared  for  in  institutions  designed  for  them,  and  about  6000  are  confined  in 
institutions  not  intended  for  their  care,  while  about  20,000  or  almost  two- 
thirds  of  the  whole,  are  at  large  in  the  community. 

An  Opportunity  for  Economy. 

With  reference  to  the  6,000  feeble-minded  who  are  cared  for  in  prisons, 
reformatories,  state  hospitals  and  almshouses,  the  state  could  be  a  large  finan- 
cial gainer  by  providing  for  them  in  custodial  institutions.  At  the  Rome  State 
Custodial  Asylum,  1,530  inmates  are  humanely  cared  for  at  $2.90  per  week. 
The  same  class  of  inmates  are  cared  for  at  the  boys'  reformatories  at  $4.66 
per  week,  at  the  girls*  reformatories  at  $5.47,  and  state  hospitals  $4.00. 
If  all  these  persons  were  transferred  to  an  institution  such  as  the  Rome  State 
Custodial  Asylum,  they  would  relieve  these  institutions  of  a  most  troublesome 
and  undesirable  class,  making  room  for  inmates  of  the  proper  class,  obviating 
the  necessity  of  enlargement.  The  money  thus  saved  would  build  ample 
institutions  for  the  care  of  these  people  and  cut  down  the  cost  of  their  main- 
tenance from  20  to  50  per  cent. 

In  view  of  the  large  number  of  the  feeble-minded  and  socially  unfit  in  New 
York  State  requiring  state  care  and  treatment  and  especially  manual  and 
industrial  training,  so  that  such  cases  may  be  saved  from  lives  of  crime  and 
immorality  and  a  large  percentage  of  them  made  happy,  industrious  and 
even  useful  laborers  and  thus  their  services  so  far  as  possible  returned  to  the 
commonwealth  and  the  individuals  trained  to  self-support  under  supervision 
and  able  to  do  the  work  for  which  there  is  a  great  but  unanswered  demand, 
namely  farm  labor  and  domestic  help ; 

Especially  as  there  is  at  present  such  great  demand  on  the  part  of  the  citi- 
zens of  the  state  for  greatly  enlarged  facilities  for  custodial  care  of  the  really 
feeble-minded: 


20I 

We  believe  that  the  time  has  come  when  something  much  less  expensiv 
and  many  times  more  practical  and  natural  than  the  physical  custody  of 
brick  walls  and  iron  enclosures  and  large  per  capita  expense  is  possible  and 
practical  to  meet  the  conditions  outlined  for  a  larger  percentage  of  these 
cases. 

First,  we  have  enuf  institutions  for  the  present  (when  such  institutions 
are  completed  and  made  available)  for  the  first  reception  and  training  of  the 
feeble-minded  children. 

With  better  facilities  for  manual,  industrial  and  vocational  training  in  our 
public  school  system  to  take  the  place  of  the  lack  of  opportunity  for  appren- 
ticeships, as  existed  in  the  past,  many  of  the  border-line  cases  will  be  saved 
in  community  life  and  will  never  need  asylum  or  custodial  care. 

Second,  from  now  on  we  should  devote  our  energies  toward  enlargement 
along  the  line  of  colonization  so  as  to  so  far  as  possible  rehabilitate  and  re- 
turn the  services  of  these  inmates  to  the  state  and  its  citizens,  thus  vacating 
many  of  the  $800.00  and  $1,000.00  beds  in  our  existing  institutions  and  mak- 
ing them  available  for  the  further  extension  of  the  training  of  younger  and 
more  socially  dangerous  cases. 

Third,  the .  services  of  many  of  the  female  adult  cases  could  well  and 
economically  be  made  available  to  large  centers  of  population  for  doing  domes- 
tic work,  hand  laundry  and  sewing,  and  thus  in  no  way  be  materially  com- 
peting with  nativ  or  naturalized  American  labor.  (At  least  20  per  cent., 
and  I  believe  40  per  cent.,  of  all  feeble-minded  and  border-line  cases  can  be 
very  successfully  and  economically  so  handled.) 

Fourth,  there  is  ample  opportunity  for  colonization  of  all  the  available 
adult  trained  males  on  various  parcels  of  state-owned  lands  and  abandoned 
or  undevelopt  farms  where  such  labor  is  especially  desirable  and  at  the  same 
time  the  individual  is  rendered  happy,  contented  and  self-sustaining  in  an 
environment  well  suited  to  his  mental  state. 

We  have  carried  on  colonization  along  these  lines  among  the  feeble- 
minded for  the  past  eight  years  and  have  proved  it  practical,  economical  and 
entirely  feasible  in  every  way. 

We  have  five  farm  colonies  with  20  inmates  and  farmer  and  wife  on  each 
where  the  22  people  are  living  comfortably  in  the  old  farmhouse  on  100 
or  more  acres  of  land,  each  such  farm  having  cost  the  State  between  $5,000 
and  $10,000,  whereas,  it  costs  to  build  large  brick  buildings  at  least  $500 
for  every  inmate. 

These  colonies  are  entirely  self-sustaining,  including  all  expense  and  5 
per  cent,  on  the  investment. 

We  also  have  one  colony  for  girls  in  a  rented  house  in  the  city  of  Rome 
where  42  girls  under  the  supervision  of  a  matron  and  a  social  worker  are  sup- 
porting themselves,  doing  domestic  work,  hand  laundry  and  sewing. 

These  statements  are  not  based  on  theory  or  abstract  thought  but  rather 
are  they  based  on  concrete  experiences,  the  results  of  twenty  years'  work  with 


202 

and  study  of  the  3,000  feeble-minded  who  have  past  thru  this  asylum  since 
its  organization  in  1894,  1500  of  whom  are  in  custody  here  at  the  present  time. 

Farm  Colonies. 

Eight  years  ago  (see  12  th  annual  report)  our  first  farm  colony  was  opened 
with  20  trained  boys  and  a  man  and  wife  on  a  farm  of  180  acres,  costing  $10,- 
000,  laying  one  mile  from  the  Asylum;  two  years  later  another  farm  colony  was 
instituted  on  an  adjoining  farm  of  20  acres,  costing  $5,000,  laying  between 
the  first  farm  colony  and  the  Asylum  farm,  and  by  dividing  the  acreage  of 
the  larger  farm  with  the  smaller  one,  making  two  colonies  of  100  acres  and 
20  inmates  each. 

Two  years  later  another  outlying  farm  of  300  acres,  five  miles  from  the 
Asylum,  was  rented  for  $650  per  year  for  use  in  growing  fodder  and  pasturage 
and  stabling  our  large  herd  of  growing  young  stock.  This  farm  is  still  rented 
and  at  present  has  thereon  100  growing  steers  which  will  be  used  for  beef, 
also  40  head  of  growing  cows  (we  have  not  purchased  a  cow  in  twelve  years 
but  have  grown  from  our  best  calves  all  the  cows  we  have,  140  at  present). 

Two  years  ago  we  purchased  a  neighboring  farm  of  60  acres  for  $5,000 
and  by  expending  $2,000  on  the  buildings  we  have  very  comfortable  housing 
accommodation  for  30  boys,  who,  with  their  house  father,  care  for  40  acres 
of  garden,  in  which  all  the  small  fruits  and  vegetables,  except  potatoes,  which 
are  grown  on  the  rented  farm,  for  our  family  of  1,800  are  grown. 

This  year  we  have  arranged  to  rent  another  farm,  a  good  dairy  farm,  of 
273  acres,  one  mile  from  the  Asylum,  for  $1,000  per  year,  on  which  we  will 
establish  a  colony  of  20  inmates  and  a  dairy  of  40  milch  cows,  their  milk  to 
be  used  entirely  for  making  butter,  of  which  we  are  at  present  making  100 
pounds  per  day,  nearly  all  we  need  for  our  regular  dietary,  in  addition  to  pro- 
ducing all  the  milk  needed. 

Agricultural  Operations. 

We  are  at  present  operating  1000  acres  of  land,  600  acres  of  which  we  own 
and  400  of  which  is  rented,  and  during  the  year  have  produced  food  supplies 
to  the  value  of  $90,000,  at  a  cost  to  the  state  of  $46,000  for  labor,  seeds,  fer- 
tilizer, farm  utensils,  stock  feed,  renewing  farm  equipment,  etc.  The  products 
included  135,000  gallons  of  milk,  27,538  pounds  of  butter,  5,300  pounds  of 
beef,  70,000  pounds  of  pork,  etc.  We  actually  butchered  forty-two  and  one- 
half  tons  of  pork  between  October  i,  1914,  and  April  i,  1915.  The  $46,000 
cost  of  farming  operations  is  included  in  the  $149.97  which  it  cost  us  per 
capita  for  maintenance  this  year  and  such  home  products  represent  one- 
fourth  of  the  total  cost  of  maintenance,  or  otherwise  one-third  of  the  net  cost 
of  such  maintenance  to  the  state.  With  a  larger  acreage  of  land  up  to  one 
acre  per  inmate  we  can  continue  to  show  a  largely  increast  percentage  of 
home  products  or  self  maintenance. 


203 

Girls'  Colony. 
The  following  announcement  was  made  at  the  opening  of  the  Colony: 

Rome,  N.  Y.,  Oct.  7,  1914. 
A  Working  Girls'  Home  has  been  establisht  at  209  W.   Thomas  St.,   telefone  number 
172-J,  where  girls  are  available  for  domestic  work,  sewing,  etc.,  by  the  day,  week,  or  month. 
The  girls  going  out  from  this  place  to  work  are  capable  of  doing  all  kinds  of  domestic  work 
except  special  cooking.     They  are  only  able  to  do  common  cooking. 

Their  services  may  be  secured  by  telefone.  The  rate  is  fifty  cents  per  day  or  thirty  cents 
per  half  day,  and  their  services  will  be  available  for  employment  at  any  time  on  short 
notice. 

Settlement  for  services  will  be  paid  direct  to  the  manager  of  the  Home.     Bills  will  be 
regularly  rendered  weekly  for  such  services. 

These  girls  are  not  defectivs,  but  are  girls  who  have  been  orphans  and 
have  never  known  the  natural  home,  and  when  later  in  life  they  have  gone 
out  into  the  world  they  have  been  unable  to  get  along  because  of  lack  of 
proper  home  training  and  natural  worldly  experience,  as  the  result  of  which 
they  were  sent  to  this  Asylum  for  study,  care  and  training,  and  we  are  sending 
them  out  to  work,  after  having  been  thoroly  trained  and  tested  here  to  see 
if  they  can  get  in  touch  with  the  world  imder  normal  conditions  and  thus  learn 
to  be  self-sustaining  and  have  their  entire  freedom. 

This  colony  is  carried  on  in  a  rented  house  in  the  city,  which  constitutes 
the  girls  home  and  social  center,  presided  over  by  a  housekeeper,  or  matron, 
with  a  social  visitor  to  inspect  their  work,  their  street  deportment,  and  to 
accompany  them  to  moving  picture  shows  and  other  social  diversions  and  to 
assist  them  in  purchasing  their  clothing,  etc.  We  hope  in  this  way  to  have 
many  of  these  girls  learn  thru  experience  normal  social  reactions  and  family 
life  and  thus  to  return  the  services  of  many  of  these  willing  and  competent 
domestic  workers  to  society  and  in  this  way  lighten  the  load  and  make  state 
care  and  supervision  possible  for  all  of  this  class  of  dependents  who  positively 
need  such  care,  and  incidentally  in  connection  therewith  we  have  establisht 
the  most  positiv  test  possible  as  to  the  ability  of  some  of  these  cases  to  rehabili- 
tate or  support  themselves,  all  of  which  we  can  never  be  positiv  of  in  a  con- 
siderable number  of  these  border-line  cases  until  some  such  world  test  has  act- 
ually been  applied. 

Of  the  67  girls  who  workt  thru  this  colony  during  the  last  year  42  remained 
at  the  end  of  the  year  and  twenty-five  were  returned  as  follows:  Nine  for 
social  offenses,  such  as  flirting  on  the  street,  boisterous  on  the  street,  noisy 
at  the  colony,  etc.,  only  two  were  really  serious  social  failures;  nine  of  the 
younger  girls  because  they  had  not  had  sufficient  training  and  seven  others 
were  retiumed  because  of  sickness  or  because  their  services  were  worth  more 
to  the  institution  than  they  were  getting  outside,  namely^  $3.50  a  week, 
and  they  preferred  to  live  and  work  at  the  Asylum. 

The  very  markt  improvement  occmring  in  these  parole  cases  is  most  favora- 
bly commented  on  by  all  who  come  in  contact  with  such  cases  and  there  is 
no  doubt  but  that  it  is  this  lack  of  these  normal  experiences  in  life  which 
caused  their  previous  failure. 


204 

FINANCIAL  REPORT,  GIRLS'  COLONY.  OCT.,  1914,  TO  OCT.,  1915. 
Total  amount  earned  during  the  year $3,278.91 

DISBURSEMENTS. 

Colony  girls  (cash  and  clothing  purchased) 1,863 .  85 

House  rent 375 .  00 

Furniture  and  furnishings 321 .  84 

Salaries 405 .  00 

Provisions 19.01 

Material  for  clothing  (colony) 10.48 

Expenses  (water  rent,  telefone,  lighting,  traveling  expenses,  enter- 
tainments, car-fare,  etc.) 273 .  56 

Balance 10. 17 

$3,278.91 

Plan  for  Further  Colonization. 

There  are  large  tracts  of  undevelopt  and  abandoned  lands  generally  scat- 
tered about  the  State,  many  of  these  owned  by  the  State,  such  as  those  re- 
verted from  tax  sales  and  State  loans  which  are  at  present  controlled  by 
the  State  Land  Board  and  the  State  Conservation  Commission,  which  lands 
(such  as  a  tract  of  8oo  acres  in  Chenango  County,  and  another  of  700  acres 
in  Blenheim,  Schoharie  County,  the  General  Kerkimer  farm  of  160  acres  in 
Herkimer  County,  another  of  400  acres  near  McConnellsville,  in  Oneida 
County,  and  many  others  listed  by  the  State  Department  of  Agriculture, 
and  regarding  which  I  have  consulted  with  them),  are  well  adapted  for  the 
use  of  male  adult  feeble-minded  as  colonies  on  which,  thru  the  expenditure 
of  very  small  amounts  of  money  for  equipment,  such  inmates  at  the  rate  of 
10  to  20  to  each  100  acres,  depending  on  the  condition  of  the  land,  can  be 
made  nearly,  if  not  entirely,  self  supporting,  such  colonies  to  be  managed 
as  a  branch  of  the  larger  institutions;  and,  too,  a  portion  of  the  services  of 
such  inmates  would  be  available  to  the  surrounding  farmers  when  they  were 
in  need  of  additional  labor,  which  at  present  they  are  unable  to  secure. 

The  State  has  purchased  the  General  Herkimer  homestead  and  farm  of 
160  acres  at  Little  Falls,  40  miles  east  from  Rome,  directly  on  the  line  of 
the  New  York  Central  Railroad  and  the  Erie  canal,  and  we  propose  that  we 
use  140  acres  of  the  farm  for  a  colony  on  which  the  boys  will  earn  their  living 
and  make  the  other  20  acres  into  a  park  surrounding  the  historic  mansion 
and  burial  place  of  General  Herkimer,  and  thus  save  the  State  the  expense 
of  such  original  work  and  care  and  upkeep. 

On  the  State  Fair  Grounds  at  Syracuse,  the  buildings  stand  vacant  355 
days  in  the  year  and  the  State  spends  large  amounts  of  money  for  common 
labor  for  the  upkeep  of  the  grounds.  We  propose  that  they  allow  us  to  take 
100  trained  boys  there  to  live  in  the  buildings  and  do  the  common  labor  for 
them,  possibly  remaining  there  all  winter  and  devising  industries  for  winter 
occupation  and  camping  under  tents  during  the  week  while  the  State  Fair 
is  on. 

The  buildings  are  good  new  concrete  buildings  with  good  toilet  facilities 


205 

and  all  we  should  need  extra  would  be  a  small  inexpensive  heating  plant, 
or  stoves  could  well  be  used,  and  here  is  an  opportunity  with  very  little  ex- 
pense to  the  State  to  house  at  least  i,ooo  trained  feeble-minded  boys,  develop- 
ing occupation  or  industries  for  them  as  the  number  gradually  increases, 
such  as  the  situation  may  at  the  time  warrant. 

There  are  along  the  banks  of  the  newly  constructed  Barge  Canal  and  its 
tributaries  large  parcels  of  land  which  were  needed  during  process  of  con- 
struction, or  were  purchased  as  a  part  of  a  whole  parcel  of  land,  which  are 
now  lying  idle  or  yielding  little  or  no  income  to  the  State,  regarding  which 
we  are  now  in  correspondence  with  General  Weatherspoon,  Superintendent 
of  Public  Works,  regarding  their  use  by  this  Asylum  as  farm  lands. 

There  are  two  especially  desirable  pieces  of  such  State  lands,  river  bottom 
and  meadow  lands,  on  the  banks  of  Lake  Delta  (817  acres  in  all),  lying  three 
or  more  feet  above  high  water  line,  which  would  make  a  most  desirable  place 
for  a  farm  colony  for  trained  boys,  and  in  the  meantime  the  property  could 
thus  be  developt  and  made  of  much  greater  value  to  the  State. 

This  land,  even  tho  owned  by  the  State,  is  at  present  squatted  on  by  sur- 
rounding farmers  and  Italian  road  laborers.  It  is  located  on  river  flats  north 
and  east  of  Lake  Delta  and  would  make  a  most  prosperous  farm  colony 
because  of  the  great  fertility  of  the  soil  in  that  region. 

Representatives  of  the  State  Department  of  Forestry  have  recently  con- 
ferred with  us  regarding  placing  a  colony  of  boys  at  Indian  Lake  to  grow  trees 
and  do  reforestration,  as  it  is  very  expensiv  to  transport  trees  and  get  labor 
there  to  do  the  work  as  at  present  carried  on.  We  have,  under  the  super- 
vision of  the  Forestry  Department,  reforested  40  acres  of  reverted  State  loan 
lands  three  miles  south  of  Rome,  and  also  about  20  acres  of  waste  land  on 
the  Asylum  farm. 

Another  scheme  is  to  colonize  on  abandoned  or  unoccupied  farms.  On 
nearly  every  cross-road  in  each  township  are  to  be  found  such  farms.  I 
would  colonize  on  such  farms,  if  possible,  and  here,  in  addition  to  earning  their 
living  on  the  farms  and  improving  the  land  and  buildings,  the  boys  can  spare 
about  one-half  of  their  time  helping  the  surrounding  farmers  who  are  much 
in  need  of  such  assistance  and  thus  the  boys  help  to  support  themselves  in 
that  way  and  during  the  spring  and  fall  and  at  other  odd  times  they  could 
pick  all  the  stone  available  and  crush  and  distribute  such  stone  on  the  small 
cross-roads,  which  serv  as  the  connecting  links  between  State  improved  roads, 
and  in  this  way  further  contribute  toward  the  uplift  of  the  rural  commimi- 
ties. 

The  Board  of  Supervisors  of  Oneida  County  has  this  road  improvement 
scheme  under  advisement  at  present. 

When  these  farms,  thru  good  cultivation,  become  sufficiently  valuable, 
they  could  well  be  vacated  as  colonies  and  the  enhanced  value,  thru  sale 
or  otherwise,  thus  revert  to  the  State  or  become  available  for  further  multi- 
plied colonization,  for  with  the  large  number  of  the  moron  type  knocking  at 


2o6 

our  doors  for  entrance  to-day  there  is  no  fear  that  we  will  soon  exhaust  the 
supply  of  either  abandoned  or  deserted  farms  or  morons. 

This  naturally  leads  us  to  the  thot,  might  not  each  county  in  the  State 
well  have  a  county  farm  colony  for  trained  adult  male  feeble-minded  under 
good  management  and  state  supervision,  whereon  all  the  necessary  food 
material  such  as  milk,  butter,  beef,  vegetables,  pork,  eggs,  fowls,  etc.,  re- 
quired for  the  almshouses  and  hospitals  and  orphans  belonging  to  such  county, 
could  be  produced  with  such  labor?  Such  county  colonies  might  be  main- 
tained somewhat  after  the  plan  known  as  the  Wisconsin  system,  wherein 
the  state  reimburses  the  county  to  the  extent  of  $ioo  for  all  cases  cared  for 
by  the  county  and  in  return  the  county  reimburses  the  state,  likewise  for  all 
cases  cared  for  by  the  state.  The  Wisconsin  system  certainly  has  to  its  ad- 
vantage the  fact  that  it  tends  to  keep  the  burden  of  the  defectiv  and  dependent 
classes  closer  to  the  home  and  the  local  community  whence  the  burden  origina- 
ted and  thus  serv  to  prevent  the  tendency  which  is  very  prevalent  in  New 
York  State  for  the  towns  and  counties  as  well  as  individuals  to  unload  their 
defectiv  and  dependent  burden  directly  on  the  State  rather  than  have  them 
in  local  institutions  at  local  expense  or  the  families  have  the  stigma,  as  they 
often  feel,  of  their  local  presence. 

It  is  very  noticeable  that  during  the  past  decade  the  type  of  the  feeble- 
minded coming  to  our  doors  for  admission  has  greatly  changed  and  that 
whereas  ten  years  ago  80  per  cent,  were  idiots  and  imbeciles  and  only  20  per 
cent,  border-line  cases  or  morons,  now  only  20  per  cent,  are  of  the  idiot  and 
imbecile  class  and  80  per  cent,  morons  and  border-line  cases.  I  believe  that 
one  reason  for  so  many  more  than  ever  before  of  these  cases  appearing  as  social 
failures  or  misfits  is  that  machinery  has  to  a  great  extent  displaced  conmion 
hand  labor  and  more  highly  organized  society  depends  more  on  co-operativ 
movements  and  thus  demands  more  specialized  ability  of  its  individual 
constituents  in  order  for  them  to  succeed,  less  low-grade  and  common  labor 
being  demanded  or  used,  and  therefore  it  becomes  us  to  endeavor  to  rehabili- 
tate these  social  misfits  or  failures  and  if  possible  get  them  back  in  touch 
with  normal  working  conditions  thru  specialized  training  (agricultural,  do- 
mestic and  household  work)  and  thus  not  only  render  themselves  self-sus- 
taining but  to  also  save  them  to  something  better  than  lives  of  institutional 
servitude. 

Especially  in  view  of  the  fact  that  a  constantly  increasing  number  of  border- 
line cases  are  appearing  at  our  institutions  and  at  Rome,  if  nowhere  else, 
many  very  doubtful  cases  (this  possibly  due  to  the  workings  of  the  law,  Chap- 
ter 448  of  Law  of  1 912,  which  allows  us  to  take  doubtful  cases  for  observa- 
tion and  study)  in  which  diagnosis  by  the  best  experts  will  differ  as  the  case 
is  seen  one  day  or  another,  there  remains  to  us,  if  we  are  at  all  conscious  of 
the  extreme  responsibility  placed  upon  us,  but  one  sure  test  as  to  the  mental 
competency  and  capacity  of  the  case  to  lead  a  normal  life  and  that  is  after 
thoro  training  the  world  test  as  provided  for  by  law  imder  Chapter  448, 
Laws  of  1912  (parole  law). 


207 

Many  of  these  cases  having  never  lived  in  normal  or  reasonable  homes  in 
which  to  learn  normal  home  and  family  life  and  many  others  having  lived 
as  children  in  great  congregate  institutions,  where  little  or  no  manual  and  in- 
dustrial training  and  especially  no  normal  family  domestic  training  was  avail- 
able, and  having  thus  become  institutionized,  the  only  fair  treatment  for 
these  doubtful  cases,  after  giving  them  such  training,  is  to  give  them  one  or 
more  favorable  trials  in  a  normal  well  selected  family  and  thus  an  opportunity 
to  round  out  such  domestic  training  and  experience,  for  does  not  every  normal 
child  develop  thru  experience  and  right  habit-forming  opportunities,  that  is, 
world  experience  and  parental  advice  when  in  danger,  and  it  is  this  method 
we  are  following  in  the  working  girls'  colony  in  Rome,  our  boys'  farm  colonies 
and  our  parole  system. 

During  the  past  ten  years  I  have  seen  many  boys  and  girls  thus  rehabili- 
tated and  the  fact  that  a  few  fail  on  the  first  trial  or  repeatedly  is  no  sure 
criterion  that  our  judgment  of  the  case  was  fallible  for  I  have  many  times 
seen  these  very  same  cases  of  failure,  almost  immediately  when  placed  in 
another  new  environment,  succeed  and  from  thence  on  make  good  and  pos- 
sibly the  previous  experience  in  failure  was  one  of  the  best  lessons  such 
cases  could  have  had.  (Were  not  all  of  us  tried  by  our  parents  and 
friends  many  times  and  often  at  the  point  of  social  failure  except  that  an  in- 
dulgent parent  was  at  hand  to  try  us  again  and  again  until  we  eventually 
found  oiu-selves?) 

The  State  of  New  Jersey  has  found  it  desirable  to  pass  a  law  requiring 
that  special  or  tmgraded  classes  in  the  pubUc  schools  of  the  state  shall  be 
carried  on  in  every  school  district  in  which  there  are  ten  or  more  children  who 
are  unable  to  make  the  grades  or  fallen  behind  in  their  regular  graded  class 
work,  and  New  York  State  in  its  larger  cities  has  estabUsht  many  such  special 
or  ungraded  classes,  especially  in  New  York  City,  Yonkers,  Rochester,  Buffalo, 
Albany,  Syracuse  and  Utica,  and  the  work  is  gradually  extending,  and  there 
is  no  doubt  that  with  better  facilities  for  manual,  industrial  and  vocational 
training  in  oiu:  pubUc  school  system  to  take  the  place  of  the  lack  of  oppor- 
tunity for  apprenticeships  as  existed  in  the  past,  many  of  the  border-line  cases 
will  be  saved  in  community  life  and  will  never  need  asylum  or  custodial 
care. 

A  report  made  by  Miss  Farrell,  Director  of  Special  Classes  in  the  New 
York  City  Schools,  in  an  address  before  the  New  York  State  Teachers'  As- 
sociation, held  at  Rochester  in  November,  and  the  report  publisht  in  the 
jomnal  called  "Ungraded"  for  December,  throws  interesting  light  on  this 
subject. 

She  states  that  a  study  of  350  children  from  these  classes  who  had  been 
in  training  in  the  New  York  City  Schools  between  1907  and  19 14  and  had 
left  the  schools,  shows  that  192,  over  one-half,  were  succeeding  at  occupa- 
tions along  the  line  of  that  which  they  had  learned  in  the  special  class  work; 
and  that  86  others  were  employed  and  cared  for  at  home  helping  at  industrial 


208 

occupations  which  were  done  in  the  home  along  the  line  of  work  they  had 
learned  to  do  at  the  schools,  such  as  sewing,  artificial  flower-making,  etc., 
31  had  been  employed  but  were  at  present  temporarily  out  of  employment 
and  only  18  had  proven  to  be  so  defectiv  that  it  was  necessary  to  send  them 
to  institutions,  and  only  3  had  fallen  into  the  hands  of  the  law  for  social 
offenses. 

In  view  of  these  facts  there  is  no  doubt  at  all  but  that  after  these  border- 
line cases  have  been  trained  in  our  institutions  they  should  be  given  an  op- 
portunity to  demonstrate  whether  or  not  they  are  able  to  support  and  care 
for  themselves,  and  that  further  special  class  work,  including  manual,  indus- 
trial and  vocational  training,  should  be  establisht  in  all  the  public  schools 
in  New  York  State  to  give  all  these  cases  a  fair  chance  before  they  fail  and 
are  sent  to  institutions. 

At  least  20  per  cent,  of  all  our  cases  and  40  per  cent,  or  more  of  all  border- 
line cases  will  thus  be  saved  to  useful  and  happy  lives  outside  of  custodial 
institutions. 

Chapter  445  of  the  Laws  of  19 12  has  practically  been  of  little  use  as  an 
eugenic  measure  in  this  State.  The  law  has  been  made  applicable  so  far  as 
possible  at  present,  to  but  one  case,  a  male  inmate  of  this  Rome  Asylum,  and 
that  only  to  the  extent  of  taking  the  case  before  the  Supreme  Court  in  Sep- 
tember, 1 9 15,  for  an  argument  as  to  the  constitutionality  of  the  law,  the  idea 
being  to  carry  the  case  to  the  Supreme  Court  of  the  United  States  as  rapidly 
as  possible. 

It  seems  that  little  or  nothing  is  to  be  gained  toward  the  control  or  ex- 
termination of  the  defectiv  classes  thru  the  application  of  this  measure,  as  it 
is  apparently  legislation  in  advance  of  public  enlightenment  if  not  contrary 
to  public  opinion;  and,  too,  were  it  applied  and  the  cases  ttuned  loose  in  the 
community  no  doubt  the  increast  spread  and  ravages  of  venereal  disease 
would  cause  such  increase  in  both  physical  and  mental  degeneracy  that  the 
number  of  defectivs  and  dependents  thus  created  would  more  than  offset 
any  diminution  in  number  of  defectivs  and  dependents  to  be  hoped  for  as  a 
result  of  sterilization,  and  as  a  moral  issue  society  can  never  afford  to  stultify 
itself  to  the  extent  of  endeavoring  to  diminish  the  cost  of  care  and  treatment 
of  the  defectiv  classes  thru  an  act  of  human  mutilation  and  then  set  such 
human  wreckage  adrift  a  prey  of,  or  a  danger  to,  his  brother  man. 


THE  STATE  AND  THE  INSANE. 

By  Richard  H.  Hutchings,  M.D..  Superintendent  of  the  St.  Lawrence    State  Hospital, 
Osdensburg,  N.  Y.,  and  Lecturer  on  Psychiatry,  Syracuse  University. 

The  thesis  which  I  shall  try  to  maintain  is  that  the  rapid  in- 
crease, during  the  last  generation,  in  the  number  of  insane  per- 
sons confined  in  our  state  hospitals  and  asylums  is  due  to  the  laws 
governing  the  admission,  detention  and  discharge  of  patients  in 
those  institutions. 

Dr.  Henry  M.  Hurd  has  pointed  out^  that  owing  to  pioneer 
conditions  the  care  of  the  insane  in  America  did  not  develop  in  a 
natural  way  to  evolve  a  system  that  was  adopted  to  the  needs 
of  the  country.  On  the  contrary,  the  dependent  classes  early 
became  identified  with  each  other.  If  harmless  the  insane  were 
bid  off  each  year  with  other  paupers  to  the  person  who  would 
care  for  them  at  the  lowest  figure.  If  excited  or  destructive,  they 
were  placed  in  pens  or  cages  in  the  almshouses  or  in  jails.  Utter 
neglect  was  the  rule  and  no  thought  seems  to  have  been  given  to 
anything  except  custody. 

The  first  institutions  to  be  establisht  for  their  care  were  organ- 
ized by  private  philanthropy,  the  Pennsylvania  Hospital,  the 
Hartford  Retreat,  Bloomingdale  Hospital,  the  Friends  Asylum, 
the  McLean  Hospital  are  examples.  These  splendily  endowed 
hospitals,  though  most  of  their  patients  are  from  the  well-to-do 
class,  stiU  care  for  a  number  of  indigent  cases.  It  is  only  when 
the  magnitude  of  the  undertaking  became  apparent  that  the 
states  began  to  make  provision  for  this  class  in  special  institu- 
tions.2 

It  is  rather  remarkable  that  as  soon  as  the  states  made  provision 
for  the  insane,  however  poor  and  incomplete  that  provision  was, 
private  philanthropy  no  longer  concerned  itself  with  the  subject. 
Though  millions  of  dollars  are  given  annually  to  hospitals  for  phys- 

^  "institutional  Care  of  the  Insane  in  the  U.  S.,"  American  Journal  of  Insanity,  1915. 
•  2  It  is  true  that  the  hospital  at  Williamsburg  was  established  by  the  Colony  of  Vir- 
ginia and  one  at  Columbia  by  the  State  of  South  Carolina,  but  according  to  Dr.  Hurd  they 
were  at  first  not  free  institutions  but  only  received  patients  whose  expenses  were  paid. 


2IO 

ical  diseases  practically  none  is  given  for  the  benefit  of  the  insane, 
and  though  education  is  admittedly  a  function  of  the  state,  yet  our 
large  universities  are,  many  of  them,  richly  endowed.  Even  when 
the  states  began  to  make  provision  for  this  class  it  was  done  re- 
luctantly.    The  case  of  New  Hampshire  may  be  cited: 

Philanthropists  viewed  with  distress  the  neglected  condition  of  the  insane 
in  county  houses  and  in  families  where  the  pauper  insane  had  been  "bid 
off"  to  the  lowest  bidder.  Petitions  poured  in  upon  the  legislature  for  the 
establishment  of  a  State  hospital.  Physicians  delivered  addresses  before 
the  legislature,  philanthropists  urged  the  measure  session  by  session  and  the 
Governors  were  most  importunate  in  their  annual  messages  and  yet  for  eleven 
years  the  agitation  continued  before  an  institution  was  established  at  Con- 
cord.' 

Is  it  to  be  wondered  at  that  the  welfare  of  the  insane  abandoned 
by  private  charity  and  unwillingly  monopolized  by  the  states, 
which  still  pursued  a  niggardly  policy  of  provision  and  care,  is 
still  one  of  the  greatest  issues  before  the  people  to-day?  When 
I  state  hospitals  were  established  it  became  necessary  to  enact 
laws  for  their  regulation.  Viewed  against  this  historical  back- 
ground, it  can  easily  be  seen  how  it  came  about  that  the  laws  then 
enacted  and  not  yet  wholly  repealed  were  admirably  designed 
to  foster  the  accumulation  of  vast  numbers  of  chronic  patients 
in  these  institutions.  The  fundamental  error,  shared  alike  by 
the  law  makers  and  the  public,  was  and  is  to  regard  insanity 
as  a  condition  and  not  as  a  disease  and  has  resulted  in  the  domi- 
nance of  the  idea  of  custody  and  not  of  prevention  and  cure. 

The  finality  of  commitment  was  the  prevalent  idea  in  the  pub- 
lic mind.  It  assumed  that  once  immured  behind  the  walls  and 
barred  windows  of  a  lunatic  asylum  there  was  little  prospect 
that  the  unfortunate  person  would  ever  be  released.  Hence  it 
was  important  to  be  sure  that  no  other  course  was  possible  under 
the  circumstances.  The  presumption  being  that  the  patient  was 
henceforth  to  be  deprived  of  his  liberty,  such  authority  could  not 
with  safety  be  left  to  medical  men  but  was  a  question  that  could 
only  be  determined  by  the  courts.  In  some  of  our  states  the  in- 
sane person  must,  even  at  the  present  time,  be  brought  into  the 
presence  of  a  judge  and  jury  and  after  the  usual  procedure  of  a 

»  Hurd,  Op.  cit. 


211 

criminal  trial,  be  duly  acquitted  or  convicted  of  having  a  disease 
which  requires  or  entitles  him  to  be  treated  in  a  special  institu- 
tion. Little  thought  was  given  to  any  feature  of  the  case  but 
that  of  danger  to  himself  or  others. 

In  the  State  of  Oregon,  even  yet,  the  petitioner  who  seeks  to 
obtain  admission  to  a  state  hospital  for  a  relative  or  friend,  must 
make  affidavit  that  he  is  dangerous  to  the  public  peace  and  well- 
fare.  It  is  true  that  physicians  were  called  in  to  examine  and 
give  evidence  and  in  some  states  one  or  two  were  required  to  be 
jurymen,  but  the  public  seemed  unwilling  to  place  much  authority 
in  their  hands  and  the  final  decision  of  what  was  essentially  a 
medical  question  was  left  in  the  hands  of  the  court. 

The  modern  view  of  the  detention  for  treatment  of  the  insane 
corresponds  more  nearly  to  our  conception  of  the  measure  of  quar- 
antine. Insanity  is  a  disease,  the  treatment  of  which  is  best 
carried  out  in  a  special  institution,  and  during  the  attack  the 
patient  is  possibly  dangerous  to  himself  or  others,  hence  his  de- 
tention in  this  special  institution,  even  against  his  will,  is  justi- 
fiable. 

The  analogy  goes  still  further.  An  insane  person  who  is  neither 
dangerous  to  himself  nor  others  and  for  whom  further  treatment 
does  not  offer  any  prospect  of  cure,  cannot  with  justification  be 
detained  if  he  can  be  suitably  cared  for  elsewhere. 

The  public  accepts  the  quarantine  regulations  of  our  boards  of 
health  and  acquiesces  in  them  so  that  interference  by  the  court 
is  almost  unknown.  This  is  due  to  two  factors.  The  first  is, 
the  public  is  able  to  recognize  the  necessity  of  sequestration  and 
second,  there  is  no  fear  that  the  detention  will  be  unduly  pro- 
longed. 

We  need  not  concern  ourselves  with  the  suggestion  that  segrega- 
tion of  the  insane  is  advisable  lest  their  offspring  swell  the  ranks 
of  the  dependent  classes  in  the  next  generation.  In  the  first  place 
the  insane,  contrary  to  popular  belief  and  in  contrast  to  the  feeble- 
minded classes,  are  not  as  prolific  as  the  normal  population.  In 
the  second  place  insanity  is  not  transmitted  as  such.  What  is 
transmitted  (except  hereditary  syphilis)  is  a  diminished  capacity 
for  adaptation  to  the  world  of  reality,  a  diminished  resiliency 


212 

to  withstand  the  buffeting  of  fortune.  Whatever  this  subnormal 
condition,  which  we  call  insane  heredity,  may  be  it  is  the  heritage 
of  the  family  and  is  shared  perhaps  equally  with  the  patient  by 
his  brothers  and  sisters  and  if  all  are  not  insane  it  may  be  only 
because  some  were  fortunate  enough  to  escape  the  difl&cult  ad- 
justment in  life  which  the  patient  encountered  and  broke  upon. 
Or  the  strain  was  softened  or  modified  for  them  by  the  existence 
of  other  interests  in  life  to  which  they  could  turn  and  which  acted 
as  safety  valves.  It  will  be  futile  to  limit  the  offspring  of  an  in- 
dividual patient  and  to  encourage  it  in  his  brothers  and  sisters. 
It  will  be  more  practical  for  us  to  busy  ourselves  with  removing 
the  obstacle  from  the  pathway  along  which  the  cripples  must 
walk  rather  than  to  confine  cripples  indoors  lest  they  fall.  How 
shall  we  go  about  to  remov-e  these  obstacles  or  to  strengthen 
the  feeble  so  that  they  may  yet  walk  in  safety? 

The  old  notion  that  insanity  comes  without  warning  like  light- 
ning from  the  sky,  striking  whom  it  would,  has  been  completely 
abandoned.  It  is  now  recognized  with  great  clearness  that  it  is 
the  culmination  of  a  long  series  of  faulty  adjustments  to  life 
which  oft-times  have  their  beginning  in  childhood.  Because  we 
have  seen  that  insanity  seemed  to  occur  by  preference  in  certain 
families,  we  have  been  too  willing  to  cover  up  our  ignorance  of 
the  true  nature  of  its  etiology  by  calling  it  hereditary,  but  a  closer 
examination  of  the  hereditary  influence  in  a  given  family  reveals 
only  contradictions  except  in  the  case  of  feeblemindedness,  the  con- 
sideration of  which  should  be  kept  entirely  distinct  from  insanity. 

If  we  look  upon  heredity  in  insanity  as  only  a  predisposition 
to  faulty  habits  of  adjustment  the  problem  of  the  prevention  of 
insanity  becomes  far  more  workable  and  at  once  it  is  seen  to  re- 
semble that  great  scourge  of  the  human  race,  tuberculosis,  for  which 
so  much  is  being  done  by  measures  of  prevention,  and  for  the  oc- 
currence of  which  heredity  was  once  a  sufficient  excuse. 

If  we  substitute  for  Koch's  bacillus  the  faulty  habits  of  adjust- 
ment the  analogy  becomes  very  close.  In  each  case  we  have  an 
individual  susceptible  to  injury  by  a  certain  cause  but  he  will 
continue  in  health  if  the  cause  can  be  avoided. 

Looked  at  from  this  point  of  view,  mental  hygiene  is  easily 


213 

thought  about  and  can  be  effectively  taught  in  the  pubHc  schools, 
from  the  lecture  platform  and  wherever  thinking  people  assemble. 

It  is  the  duty  of  the  profession  to  disseminate  the  principles 
of  mental  hygiene  as  is  being  done  in  the  case  of  tuberculosis 
and  where  else  should  we  look  for  leadership  in  this  movement 
except  to  the  hospitals  for  the  insane? 

Why  have  the  hospitals  for  the  insane  not  taken  a  more  active 
part  in  this  movement?  The  answer  is,  because  they  have 
not  recognized  the  opportunity.  They  have  been  working  with 
the  ashes  and  cinders,  amid  the  ruins  of  once  fair  structures  and 
had  no  knowledge  of  the  faulty  construction  of  the  building  or 
of  the  nature  of  the  combustibles  that  were  stored  in  it.  This  is 
where  we  get  a  view  of  the  baleful  results  of  the  laws  to  which  I 
have  already  alluded. 

The  state,  in  the  exercise  of  its  monopoly  of  the  treatment  of 
the  insane,  says  who  shall  be  treated  and  when  the  treatment 
may  begin.  He  must  be  dangerous,  he  must  be  suicidal,  the 
public  peace  and  welfare  must  be  menaced  by  his  presence, 
therefore  in  the  majority  of  cases  he  must  be  incurable.  It  mat- 
tered not  that  the  patient  himself  felt  that  something  was  going 
wrong  with  his  mind  and  fearful  for  his  sanity  knocked  at  the 
door  of  the  asylum  and  asked  for  help.  **No  indeed,"  he  was 
told,  "We  only  take  in  lunatics,  the  fact  that  you  ask  for  admis- 
sion indicates  that  you  have  reason  and  judgment.  Go  away 
until  you  become  certifiable." 

But  few  of  the  States  permit  voluntary  admissions  and  those 
only  in  recent  years.  The  wealthy  and  progressive  state  of 
Ohio  tolerates  voluntary  patients  in  its  state  institutions,  but 
lest  their  numbers  should  overtax  the  existing  facilities  for  car- 
ing for  the  chronics  the  number  in  each  hospital  is  limited  to 
five. 

The  situation  is  exactly  the  same  as  if  the  hospitals  for  tuber- 
culosis should  refuse  to  receive  the  incipient  cases  and  admit 
only  those  in  the  advanced  stages  of  the  disease. 

New  York  has  provided  for  voluntary  admissions  since  1909, 
and  last  year  425  such  cases  were  treated  in  the  state  hospitals, 
and  the  recovery  rate  in  this  class  is  high. 


214 

The  scope  of  my  paper  does  not  justify  a  detailed  discussion 
of  practical  measures  of  prevention  and  I  shall  say  only  enough 
to  point  out  the  importance  of  this  work.  That  much  can  be 
done  in  this  direction  has  become  manifest  by  the  recent  advances 
in  our  knowledge  of  the  role  of  syphilis  and  alcohol,  two  definite 
and  easily  preventable  causes  which  together  account  for  more 
than  a  quarter  of  the  admissions  directly  and  enter  as  a  contribu- 
tory factor  in  a  much  larger  proportion. 

Some  very  useful  work  is  now  being  done  in  demarking  the 
various  types  of  individuals,  the  characteristics  of  which  are 
shown  at  an  early  age.  Hoch  has  pointed  the  way  by  his  delinea- 
tion of  the  shut-in  child,  among  the  ranks  of  whom  nearly  all  the 
cases  of  dementia  praecox  are  later  recruited. 

The  burden  of  the  custodial  care  of  the  unrecovered  patients 
has  grown  greater  year  by  year.  In  the  State  of  New  York, 
with  10,000,000  inhabitants  caring  for  33,000  insane,  the  annual 
increment  is  about  one  thousand  patients,  which  is  the  equiva- 
lent of  a  new  large  hospital  every  second  year.  That  State  for 
next  year  has  appropriated  for  the  support  of  the  insane  the  sum 
of  $8,136,076  and  it  is  estimated  that  to  relieve  the  present  over- 
crowding and  provide  reasonably  for  the  future,  $25,000,000 
should  be  made  available  at  once. 

At  first  glance  these  look  to  be  staggering  figures,  but  that  State 
is  growing  in  population  at  the  rate  of  200,000  per  annum  and 
has  a  large  proportion  of  foreign  born  among  whom  the  ratio 
of  insanity  is  much  higher  than  among  the  native  population. 

It  is  my  conviction,  based  upon  observation  of  25  years,  that 
if  there  is  any  increase  at  all  in  insanity  in  the  native  popula- 
tion it  is  relatively  small.  State  hospitals  have  become  popular, 
the  old  horror  of  them  is  passing  away  and  there  is  an  increasing 
tendency  to  commit  to  them  old  and  harmless  dements  whose 
care  at  home  was  a  matter  of  duty  and  family  pride  a  generation 
ago.  More  than  half  of  our  patients  are  beyond  fifty  years  of 
age. 

No  sooner  is  the  old  person  removed  from  the  household,  be- 
cause of  some  transient  excitement  or  depression  which  renders 
his  further  care  at  home  diflftcult,  than  the  family  re-adjusts 


215 

itself  to  his  absence.  The  finaHty  of  commitment  is  accepted, 
often  the  family  disintegrates,  the  members  taking  up  new  in- 
terests, the  house  may  be  disposed  of.  A  few  months  later  the 
excitement  or  depression  has  passed  off  and  he  is  again  in  his 
former  condition  of  quiet  dementia  and  could  be  suitably  cared  for 
in  a  private  house,  but  no  home  is  open  to  him.  One  of  that 
year's  increment  is  accounted  for. 

As  it  is  important  to  provide  for  early  treatment,  it  is  equally 
important  to  provide  for  prompt  discharge  when  residence  in 
the  hospital  offers  no  further  benefit  to  the  patient  or  the  com- 
munity. 

The  state  hospitals  should  be  training  schools  for  physicians 
and  nurses  desirous  of  doing  special  work  in  psychiatry  and  their 
facilities  under  the  direction  of  competent  instructors  should  be 
made  more  generally  available,  both  for  students  and  for  post- 
graduate work.  The  number  of  physicians  in  general  practice 
who  have  had  an  adequate  training  in  psychiatry  is  deplorably 
small  and  they  are  to  be  found  as  a  rule  only  in  the  larger  cities. 
The  result  is  that  early  symptoms  of  mental  disorders  escape 
recognition  or  are  treated  with  tonics  or  hypnotics  where  often 
a  searching  inquiry  into  the  patient's  history  would  reveal  the 
true  cause  to  be  a  conflict,  perhaps  a  difficult  domestic  situation, 
to  which  he  cannot  adjust  himself  but  which  the  advice  and  author- 
ity of  the  physician  could  speedily  remedy.  Until  this  is  done  medi- 
cation is  useless  and  foolish.  Two  recent  cases  come  to  mind  as 
illustrations,  both  women  with  symptoms  of  melancholia,  loss 
of  interest  in  life  and  discouragement.  In  one  case  a  mother- 
in-law,  and  in  the  other  a  sister-in-law  were  eliminated  from  the 
family  by  my  advice  with  happy  results.  Neither  of  these  patients 
attributed  their  depression  to  its  real  cause  but  supposed  as  their 
physicians  did,  that  it  had  a  physical  basis. 

It  cannot  be  expected  that  the  general  practitioner  will  acquire 
more  than  the  fundamentals  of  psychiatry  but  even  these  have 
not  been  given  in  the  medical  schools  with  but  few  exceptions 
and  only  recently.  The  revolutionary  changes  in  our  concep- 
tion of  the  nature  and  causes  of  mental  disorders  which  have  been 
taking  place  during  the  last  ten  years  have  left  the  general  prac- 


2l6 

titioner  far  behind.  The  result  is  that  the  knowledge  which  has 
been  gained  of  the  nature  and  particularly  the  causes  of  mental 
disease  are  not  being  utilized  in  a  practical  way. 

That  the  care  of  the  insane  must  remain  a  state  monopoly 
is  inevitable  from  the  magnitude  of  the  undertaking  and  the  time 
has  now  come  when  for  his  own  protection  it  must  do  more  than 
care  for  the  advanced  cases  committed  by  the  courts.  It  must 
take  measures  to  conserve  the  mental  health  of  its  citizens  in  as 
vigilant  and  practical  a  way  as  the  boards  of  health  now  deal 
with  communicable  diseases.  This  can  be  done  by  fostering 
the  establishment,  under  state  supervision,  of  local  agencies  in 
cooperation  with  the  state  hospitals,  such  as  psychopathic  wards 
in  general  hospitals,  mental  clinics  or  dispensaries  and  the  em- 
ployment of  physicians  1  and  nurses  as  field  agents  to  assist  in 
the  care  of  patients  in  their  homes. 

There  should  be  established,  under  state  supervision  and  with 
state  aid,  in  one  local  hospital  in  every  town,  a  psychopathic 
ward  for  the  early  treatment  of  mental  cases  requiring  such  care 
and  a  dispensary  where  physicians  may  come  with  their  patients 
for  consultation  and  advice.  The  physicians  in  charge  of  this 
work  should  be  attached  to  the  staff  of  the  nearest  state  hospital 
and,  to  insure  thorough  cooperation  with  and  control  by  the  parent 
institution,  he  should  receive  at  least  a  part  of  his  remuneration 
from  the  state. 

The  attempts  of  small  political  divisions  as  counties  and  towns 
independently  to  care  for  the  insane  have  not  worked  out  suc- 
cessfully. This  is  so  well  known  as  to  require  no  elaboration  in 
this  paper,  but  the  state  hospitals  are,  in  nearly  every  state,  in 
responsible  hands  and  the  standards  are  as  good  as  the  legisla- 
ture will  support.  Hence  the  suggestion  that  the  local  psycho- 
pathic wards  and  dispensaries  should  be  placed  in  charge  of  physi- 
cians who  are  members  of  the  staff  of  the  state  hospital  and 
subject  to  its  authority.  Such  details  of  men  for  special  duties 
are  common  in  the  army  as  instructors  in  military  schools,  etc., 
and  with  a  minimum  income  guaranteed  such  positions  would 

1  The  suggestion  to  employ  physicians  for  this  work  is  not  new.     Connelly,  as  long  ago 
as  1820,  suggested  the  employment  of  externes  for  this  purpose. 


217 

prove  attractive  to  the  older  and  best  qualified  men  in  the  ser- 
vice. In  this  way  very  close  cooperation  could  be  secured  be- 
tween the  hospital  and  the  local  establishments.  Every  patient 
would  first  be  under  the  care  of  the  resident  alienist  and  only 
upon  his  advice  and  for  satisfactory  reasons  would  he  be  passed 
on  to  the  state  hospital,  and  as  soon  as  was  deemed  advisable 
the  patient  would  be  returned  to  him  for  observation  and  care 
during  convalescence.  This  would  help  to  prevent  the  loss  of 
interest  in  the  patient  by  his  family.  Many  unrecovered  cases 
could  live  at  home  in  safety  and  comfort  under  his  tutelage, 
where  now,  with  no  trained  supervision,  the  hospital  authorities 
feel  reluctant  to  discharge  them. 

That  psychopathic  hospitals  diminish  the  number  of  commit- 
ments to  state  hospitals  has  already  been  demonstrated.  The 
Psychopathic  Hospital  at  Ann  Arbor,  Mich.,  found  it  necessary 
to  commit  only  28  per  cent,  of  its  patients.  The  Psychopathic 
Hospital  at  Syracuse,  N.  Y.,  committed  only  95  of  the  245  patients 
admitted  and  apparently  insane,  38  per  cent.  Pavilion  F,  the 
Psychopathic  Ward  of  the  Albany  General  Hospital,  the  pioneer 
institution  of  this  kind  and  one  that  is  exceptionally  well  organ- 
ized and  conducted,  last  year  cared  for  410  patients,  of  whom 
only  113  were  committed  to  state  hospitals,  27  per  cent.  The 
average  period  of  treatment  was  23  days  and  the  average  number 
of  patients  in  the  Ward  was  25. 

Dr.  J.  M.  Mosher,  the  attending  specialist  in  mental  diseases 
(and  who  was  formerly  first  assistant  physician  in  the  St.  Law- 
rence State  Hospital),  makes  the  following  comment  in  his  annual 
report : 

As  the  feasibility  of  the  treatment  of  mental  diseases  in  a  general  hospi- 
tal has  become  more  widely  known  during  the  thirteen  years  of  operation  of 
Pavilion  F,  there  has  followed  a  growing  appreciation  of  the  fact  that  ab- 
normal conditions  of  the  mind  are  not  necessarily  attended  by  loss  of  personal 
responsibility,  or  so  complete  defect  of  judgment  as  to  render  the  victim 
unable  to  acquiesce  in  measures  taken  for  his  relief. 

Intelligent  appreciation  of  his  condition,  sympathy  with  his  distress, 
coming  with  an  opportimity  to  place  him  under  systematic  treatment,  and 
without  formality,  publicity  or  legal  technicality,  all  contribute  to  his  acqui- 
escence in  the  suggestion  that  he  enter  the  hospital.     In  many  cases  the  res- 


2l8 

toration  to  health  is  relatively  rapid,  and  the  recovery  of  many  patients 
in  a  comparatively  short  time,  has  been  a  surprising  revelation  of  the  effec- 
tiveness of  an  institution  of  this  kind. 

Results  of  an  encouraging  kind  have  followed  the  establish- 
ment of  mental  dispensaries  in  Massachusetts  and  New  York 
and  the  reports  show  that  the  attendance  has  been  unexpectedly- 
large.  Briggs  and  Stearns,^  in  a  report  on  the  work  being  done 
along  this  line  in  Massachusetts,  say:  **At  the  end  of  seven 
months  we  can  say  that  the  out-patient  department  has  proved 
a  success  and  has  met  the  fondest  hopes  of  the  board."  At  one 
of  these  dispensaries  in  the  City  of  Boston  358  visited  in  one 
month. 

We  shall  make  little  real  headway  against  what  is  popularly 
called  "the  rising  tide  of  insanity"  until  facilities  are  provided 
for  adequately  dealing  with  the  incipient  cases.  The  public 
appears  to  have  almost  no  proper  conception  of  this  problem. 
The  unfortunate  terms  "sane"  and  "insane"  are  real  hindrances 
to  progress:  it  would  be  well  for  us  if  they  could  be  blotted  from 
the  dictionaries.  Any  degree  of  mental  illness  or  inefficiency 
is  important  enough  for  thorough  investigation  and  correction; 
and  let  us  not  confuse  the  issue  by  consideration  of  such  subjects 
as  legal  responsibility,  testamentary  capacity,  etc.,  which  are 
lawyers'  terms  and  not  useful  in  the  consideration  of  the  case  as 
a  medical  problem. 

If  we  could  stop  thinking  about  insanity  and  provide  hospitals, 
dispensaries  and  clinics  for  the  treatment  of  mental  illness  of  all 
degrees  we  should,  for  a  time  at  least,  have  more  work  to  do 
but  would  make  some  real  progress  w^here  now  we  are  marking 
time. 

Dr.  Ray  Lyman  Wilbur: 

I  have  just  come  in  but  I  want  to  particularly  thank  the  author  for  this 
paper.  We  have  tried  in  California  to  get  the  public  interested  in  the  care 
of  the  insane  along  the  lines  indicated  therein  but  have  found  it  very  difficult 
to  do.  The  matter  requires  the  coordinated  efforts  of  the  physician  and  the 
lawyer.  The  legal  profession  is  loath  to  give  up  the  insane  man  to  the  physi- 
cian.    I  feel  that  we  should  confer  with  the  bar  associations  of  the  different 

1  L.  Vernon  Briggs,  M.D.,  and  A.  Warren  Stearns,  M.D.:  "Recent  Extension  of  Out- 
patient Work  in  Massachusetts  State  Hospitals."     American  Journal  of  Insanity,  1915. 


219 

states  of  the  Union  and  try  to  convince  them  that  they  ought  to  join  with 
us  in  asking  for  new  legislation  along  this  line.  We  know  the  facts  from 
the  medical  standpoint;  we  know  the  statistics,  and  it  seems  to  me  that  we 
should  appeal  strongly  to  the  attomeys-at-law  in  their  various  organizations 
to  help  us  correct  the  very  gross  and  barbaric  abuses  associated  with  the  care 
of  the  mentally'sick  that  we  allow  now  to  go  on  in  this  Republic. 

Dr.  Tom  A.  Williams,  Washington,  D.  C. : 

This  is  an  exceedingly  important  matter  of  practical  expediency,  and  can 
be  approacht  from  many  different  angles.  I  speak  from  the  angle  of  the  man 
who  sees  these  various  patients  when  they  are  in  the  incipiency,  and  is  con- 
scious of  the  difficulties  of  handling  such  persons  under  the  present  legisla- 
tion. While  we  ought  to  find  these  patients  in  the  incipiency  of  the  disease, 
it  is  not  always  done  because  the  average  medical  man  cannot  recognize  them ; 
and  because  the  patient  who  loses  his  grip  will  not  go  to  the  only  place  where 
he  at  present  can  go,  viz.,  to  the  asylum  for  the  insane.  I  know  this  from 
personal  observation.  A  patient  has  often  refused  to  allow  his  doctor  to  call 
me  because  he  thinks  I  will  commit  him.  It  is  obvious,  therefore,  that  we 
must  make  it  easy  for  the  sick  man  to  seek  assistance  without  the  fear  of 
being  interned.  There  is  only  one  way,  viz.,  that  the  man  who  feels  himself 
that  he  is  losing  his  mental  grip  shall  regard  himself  as  merely  a  case  of 
"nerves,"  as  the  laity  call  it,  and  be  willing  to  go  to  the  general  hospital  as 
any  other  sick  man  would.  This  is  not  done,  because  in  the  ordinary,  general 
hospital  the  man  in  charge  is  not  fully  equipt  for  this  work.  He  has  no  con- 
ception of  the  problem  he  is  dealing  with. 

The  fact  that  so  much  can  be  done  for  these  cases  has  been  amply  proven. 
For  instance,  while  detailed  to  the  Naval  Hospital  in  Washington,  Captain 
Sheehan  from  his  experience  decided  that  the  Federal  Asylum  for  the  In- 
sane was  not  the  place  for  the  incipient  case  in  a  navy  man,  but  that  such 
cases  should  be  treated  in  the  general  hospital.  The  naval  authorities  who 
were  opposed  to  his  plans  are  now  enthusiastic  about  what  has  been  done 
for  the  men  and  officers  in  this  very  clinic.  The  secret  of  success  is  that  the 
man  in  charge  of  such  an  organization  must  be  a  neurologist,  a  medical  man, 
a  psycho-pathologist  and  a  psychiatrist,  thus  covering  the  whole  of  the  dis- 
orders of  the  nervous  system. 

There  is  now  an  effort  to  make  the  insane  hospital  available  to  the  public. 
It  cannot  be  done;  there  will  always  be  the  stigma.  Treatment  must  be 
given  the  incipient  cases  thru  the  general  hospital  in  special  neurologic  or 
nervous  service.  I  believe  that  is  the  easiest  solution  of  the  whole  problem. 
It  has  long  been  done  in  Paris,  where  the  psychiatric  and  neurologic  services 
are  taken  advantage  of  with  great  readiness  by  the  people  of  that  city. 


THE   NECESSITY   FOR    MEDICAL    EXAMINATION    OF 
PRISONERS  AT  THE  TIME  OF  TRIAL. 

By  Paul  B.  BowBRS,  M.S.,  M.D.,  Med.  Supt.,  Indiana  Hospital  for  Insane  Criminals, 

Michigan  City,  Ind. 

There  is  very  adequate  excuse  for  presenting  an  address  of 
this  title.  Evidences  of  the  gross  miscarriage  of  justice  and  of 
the  inadequate  protection  afforded  the  pubHc  are  to  be  found  in 
every  penal  institution  of  this  country.  I  wish  it  to  be  under- 
stood as  a  preface  to  my  remarks,  that  what  I  have  to  say  is  de- 
void of  maudlin  sentiment  and  the  chief  purpose  that  I  have  in 
mind  is  the  protection  of  the  public  from  the  individuals  who 
offend  society  and  violate  her  laws  by  reason  of  deliberate  vicious- 
ness,  or  from  social  or  economic  determinism,  or  because  of  men- 
tal unsoundness. 

Every  year  society  is  unjustly  sending  to  prison  hundreds  of 
insane  and  feeble-minded  persons  who,  in  the  course  of  their  mental 
disturbances,  have  violated  the  penal  laws.  And  this  culpable 
practice  of  punishing  the  mentally  sick  in  penal  institutions 
should  "in  the  course  of  justice,"  cease. 

Society  is  being  poorly  protected  when  it  sends  insane  and 
mentally  defective  individuals  to  penal  institutions  and  then  re- 
leases them  uncured  from  custody,  merely  because  their  sentences 
have  expired.  Yet  this  irrational  procedure  is  being  practiced 
continuously  by  our  courts  and  boards  of  parole  in  all  the  states 
of  the  Union. 

Up  to  the  present  time,  far  more  attention  and  consideration 
have  been  given  to  the  legal  classification  of  crime  and  to  its 
various  modes  of  punishment,  than  have  been  given  to  the  crim- 
inal himself. 

Probably  50  per  cent,  of  all  juridical  proceedings  are  concerned 
with  criminality,  and  yet  our  jurists  placidly  and  contentedly 
continue  to  study  their  books  instead  of  men,  searching  in  pon- 
derous and  ancient  volumes  of  citations,  resurrecting  decisions 
from  the  legal  grave-yard  of  the  dead  past  and  with  these  crumb- 


221 

ling,  moth-eaten  and  time-worn  precedents,  they  attempt  to  regu- 
late the  anti-social  conduct  that  springs  from  a  disordered  men- 
tality. Let  us  briefly  survey  the  results  of  committing  insane  and 
mentally  defective  individuals  to  prison.  When  a  defective 
delinquent  has  been  discharged  or  paroled  from  custody  merely 
because  he  has  spent  a  certain  time  in  prison,  he  returns  to  society 
a  more  defective  and  viciously  inclined  individual  than  he  was 
previous  to  his  incarceration  and  it  is  almost  certain  that  he 
will  return  to  prison  on  a  new  charge,  and  the  same  foolish  ex- 
periment with  all  its  attendant  expense  will  be  repeated. 

In  a  recent  study  that  I  made  of  one  hundred  recidivists  all 
of  whom  had  been  convicted  not  less  than  four  times,  twelve  of 
them  were  insane,  twenty-three  were*  feeble-minded,  ten  were 
epileptic,  and  in  each  instance  the  mental  defectiveness  bore  a 
direct  causal  relation  to  their  crimes.  No  less  than  one  hundred 
and  eighty  trials  have  been  held  for  these  persons;  it  is  reported 
by  good  authority  that  it  costs  no  less  than  $i,ooo  to  convict  a 
prisoner,  so  at  this  rate  the  lowest  possible  expense  to  the  com- 
monwealth was  $180,000.  And,  four  times  each  one  of  these 
defective  individuals  had  been  released  to  prey  upon  society 
and  no  permanent  good  whatsoever  has  been  accomplished. 

The  presence  of  insane  persons  in  penal  institutions  is  ex- 
tremely detrimental  to  discipline,  for  they  cannot  be  punished 
as  a  normal  prisoner  should  be,  because  of  their  defective  sense 
of  responsibility,  and  advantages  are  taken  of  this  humanitarian 
leniency  by  the  more  intelligent  prisoner  to  commit  offences 
against  the  rules.  No  less  than  seventy-five  per  cent,  of  the  men 
who  appear  before  the  disciplinary  officer  of  the  Indiana  State 
Prison  are  mentally  defective. 

What  have  been  the  reasons  that  this  outrage  has  been  per- 
mitted to  exist  as  a  blot  upon  the  escutcheon  of  our  social  jus- 
tice? Why  have  we  stigmatized  mentally  sick  individuals  as 
criminals?  The  answer  is  to  be  found  in  our  ignorance  of  the 
psychology  of  crime,  in  the  spirit  of  laisser  faire  of  the  legal 
fraternity  who  have  always  been  exceedingly  slow  to  eradicate 
the  evils  of  our  legal  procedure  and  who  have  ever  sought  the  pro- 
tection of  bristling,  misleading  technicalities  and  that  much  abused 


232  , 

legal  phrase  "constitutional  rights"  when  legal  reforms  have  been 
imminent.  While  admitting  that  the  constitutionality  of  any- 
legal  procedure  must  be  determined,  it  is  at  once  appreciated 
by  every  fair-minded  person  that  all  social  reforms  of  a  legal 
nature  have  usually  met  with  serious  opposition,  possibly  be- 
cause these  suggested  changes  have  been  thought,  at  least  for 
a  while,  to  be  too  radical  and  revolutionary. 

Since  these  mentioned  ills  and  many  others  attend  our  criminal 
law  practice,  the  question  at  once  arises,  what  shall  we  do  in  the 
matter?  It  is  at  once  apparent  that  our  defective  methods  of 
dealing  with  prisoners  spring  from  a  number  of  various  causes 
which  are  complexly  related  and  no  one  single  remedy  that  might 
be  offered  will  be  a  panacea  for  the  relief  of  them,  but  I  am  of  the 
firm  belief  that  the  medical  and  psychiatric  examination  of  prison- 
ers at  the  time  of  trial  would  go  a  long  way  in  the  solution  of 
the  vexing  criminal  problems. 

Under  no  circumstances  should  there  be  any  attempt  to  abridge 
the  right  of  trial  or  for  the  court  physician  to  usurp  the  authority 
of  the  judge  or  jurors  but  it  is  obviously  apparent  that  the  court 
should  be  supplied  with  scientific  data  concerning  the  alleged 
criminal.  The  facts  of  the  violation  of  law  should  be  first  care- 
fully determined  by  the  court  and  the  report  of  the  mental  in- 
vestigation be  submitted  to  the  judge  before  the  sentence  has 
been  pronounced,  except  in  those  cases  where  the  alleged  criminal 
is  so  manifestly  insane  that  he  cannot  in  the  least  comprehend 
that  he  is  being  tried.  This  information  would  furnish  the  judge 
and  court  with  the  knowledge  that  would  enable  them  to  more 
accurately  decide  whether  the  individual  should  have  a  suspended 
sentence  or  be  sent  to  prison,  to  a  hospital  for  the  insane,  or  placed 
in  the  hands  of  a  probationary  officer. 

It  is  well  understood  that  such  a  change  in  our  criminal  methods 
would  be  met  with  a  storm  or  protest  from  our  legal  friends. 
They  very  probably  would  consider  such  a  change  extremely 
idealistic  and  impracticable ;  that  it  would  interfere  with  the  func- 
tions of  the  jury  and  that  the  right  of  the  defendant  to  employ 
witnesses  would  be  curtailed  and  upon  casual  consideration, 
these  objections  seem  to  be  logical  and  valid.     But  when  we  re- 


223 

fleet  that  the  real  purpose  of  the  law  is  justice  and  truth  and 
not  the  preservation  of  hair-splitting  technicalities,  we  cannot 
hold  these  objections  to  be  of  great  worth. 

The  medical  examination  of  prisoners  would  correct  in  a  large 
measure  the  evils  that  attend  the  employment  of  medical  experts. 
Much  of  the  criticism  which  is  unjustly  and  malignantly  heaped 
upon  the  qualified  and  honest  psychiatrist  would  be  done  away 
with  and  many  of  the  unqualified  practitioners  who  are  posing 
as  mental  experts  and  thereby  bringing  ill-repute  upon  the  med- 
ical profession  would  be  eliminated  from  court  practice.  It  is 
the  height  of  medical  absturdity  to  permit  a  general  practitioner 
who  is  without  knowledge  and  experience  in  psychiatry,  to  give 
opinions  and  statements  in  coiuts  which  are  likely  to  affect  the 
life  or  liberty  of  an  individual.  Our  present  method  of  em- 
ploying expert  testimony  is  productive  of  but  little  good  and  of 
a  great  deal  of  harm.  Our  present  system  makes  the  alienist 
an  interested  party  to  the  issue  in  question  and  it  is  exceedingly 
difficult  for  the  alienist  no  matter  how  well  qualified  and  honest, 
to  give  testimony  that  is  entirely  satisfactory  to  his  own  con- 
science and  to  the  merits  of  the  case  in  hand. 

Now  the  physicians  are  hired  by  the  plaintiff  and  the  defendant 
and  pitted  against  one  another  in  a  wordy  battle  for  the  display 
of  wits  by  lawyers  who  are  skillful  rhetoricians,  who  cunningly 
and  skillfully,  by  the  use  of  dialectics,  suppress  medical  facts 
dangerous  to  their  own  purposes  and  lay  undue  stress  on  non- 
essentials if  they  can  thereby  gain  any  advantage  over  their 
opponents. 

Very  equivocal  hypothetical  questions  are  presented  which  are 
often  not  supported  by  salient  facts  and  the  doctor  is  required 
to  answer  the  unproven  statements  without  the  privilege  of  due 
and  careful  consideration.  The  individual  of  the  hypothetical 
question  and  the  person  on  trial  often  seem  to  bear  only  the  faintest 
traces  of  kinship  to  one  another. 

To  correct  some  of  these  wrongs  that  I  have  enumerated,  the 
court  should  appoint  a  physician  who  is  qualified  by  training 
and  experience  in  the  science  and  practice  of  psychiatry.  This 
physician  should  be  a  part  of  the  personnel  of  the  court  and  it 


224 

should  be  his  duty  to  sociologically,  physically  and  mentally 
examine  every  prisoner  at  the  time  of  his  arrest  and  trial.  A 
carefully  written  detailed  report  should  be  made  out  and  presented 
to  the  court  for  the  instruction  of  the  judge  and  jiurors.  If  this 
were  the  case,  many  of  the  unnecessary  trials  that  are  now  being 
held  would  be  done  away  with  and  much  needless  expense  would 
be  saved.  Under  this  procedure,  the  malignerer  would  be  de- 
tected and  the  insanity  dodge  would  become  very  much  less 
popular.  Many  of  the  individuals  suffering  from  the  incipient 
insanities,  whose  crimes  are  but  the  expression  of  mental  disease, 
would  have  their  psychical  disorders  discovered  early  enough 
that  they  might  be  sent  to  hospitals  for  the  insane  for  cure  in- 
stead of  being  forced  to  linger  in  prison  cells  medically  neglected 
and  misunderstood. 

That  the  results  of  the  examinations  may  be  accurate,  logical, 
uniform  and  impartial,  a  definite  outline  of  examination  should 
be  adopted  and  should  be  strictly  adhered  to  both  in  spirit  and 
application.     The  steps  of  examination  should  be  as  follows: 

a.  An  accurate  family  history  should  be  obtained  having  a 
special  reference  to  the  inheritance  of  disease  especially  insanity, 
feeble-mindedness,  epilepsy  and  criminality,  together  with  a  care- 
ful siUT^ey  of  the  social  conditions. 

b.  An  accurate  personal  history  of  the  accused. 

c.  An  accurate  physical  and  neurological  examination  of  the 
accused. 

d.  An  accurate  mental  examination  which  should  follow  the 
latest  methods  employed  in  modern  hospitals  for  the  insane 
and  schools  for  the  feeble-minded. 

e.  A  complete  typewritten  statement  of  these  findings  should 
be  made  including  a  brief  conclusion,  diagnosing  the  intelligence 
of  the  criminal,  his  moral  nature,  the  criminal  type  to  which  he 
belongs  and  the  degree  of  his  dangerousness  to  society.  A  copy 
of  this  report  should  be  filed  with  the  records  of  the  case  in  the 
cotui:  where  the  trial  is  held  and  with  the  State  Board  of  Correc- 
tions and  Charities  open  to  public  inspection  at  any  time. 

The  physician  in  his  routine  examination  of  prisoners  charged 
with  crime  would  find  every  variety  of  the  essential  psychoses 


225 

and  all  anomalous  psychotic  states  represented  and  unless  the 
alienated  individuals  committed  crimes  of  violence  and  dis- 
played dangerous  criminal  tendencies  it  would  be  apropos  to 
send  these  persons  to  the  ordinary  hospitals  for  the  insane.  The 
medical  examiner  would  find  another  class  of  mentally  defective 
prisoners  comprised  of  the  instinctive  or  bom  criminals,  the 
dangerous  epileptics  and  paranoiacs,  the  sexual  perverts  and  the 
morally  insane. 

The  most  dangerous  of  all  insane  patients  is  the  one  who  har- 
bors in  the  recesses  of  his  diseased  mentality  systematized  delu- 
sions of  persecution.  This  is  especially  true  of  the  paranoiac, 
who  many  times  appears  to  be  intellectually  normal  and  occa- 
sionally, aside  from  his  paranoidal  tendencies,  he  may  be  the 
superior  to  the  average  individual.  The  proper  perspectives 
of  life  are  impossible  for  the  paranoiac  since  each  instance  and 
circumstance  is  colored  and  tinged  by  an  abnormal  sensibility 
and  reaction  to  the  most  common  place  and  trivial  affairs. 

The  paranoiac  in  the  stage  of  persecution,  out  of  the  most  in- 
significant circumstance,  constructs  a  nebula  of  persecutory 
ideas  which  are  intangible  and  obscure.  Finally  these  hazy, 
indistinct  ideas  of  persecution  take  on  a  more  definite  character, 
and  then  step  by  step,  supportive  and  contributive  ideas  are  formed 
and  elaborated  which  build  up  a  definite,  systematized,  delusional 
preconception  or  system  of  thought,  through  which  must  pass  every 
idea  that  is  translated  into  action. 

This  delusional  formation  is  so  closely  and  intimately  connected 
with  the  whole  of  consciousness,  that  it  regulates  and  dominates 
the  individual's  manner  of  feeling,  thinking  and  acting.  It  is 
easy  to  see,  therefore,  that  any  paranoiac  is  a  potential  homicide 
while  harboring  delusions  of  persecution.  Should  he  believe 
that  his  supposed  enemies  have  designs  upon  his  life,  or  that  they 
desire  to  make  him  the  butt  of  their  ridicule,  or  the  object  of  some 
diabolical  conspiracy,  it  is  not  at  all  strange  that  the  persecuted 
should  ttun  persecutor. 

The  types  that  have  just  been  mentioned  should  not  be  con- 
fined in  the  ordinary  prisons  nor  should  they  be  sent  as  unwel- 
come guests  to  mingle  and  associate  with  the  ordinary  innocent 


226 

and  non-dangerous  insane.  These  types  of  mentally  defective 
prisoners  are  the  first  brands  of  insubordination  and  mutiny 
and  they  are  a  perpetual  menace  to  the  discipline  of  any  institu- 
tion and  possibly  to  the  lives  of  institutional  officials. 

To  confine  them  in  common  asylums  would  be  *  *  *  *  injtuious,  for  they 
preach  sodomy,  flight,  and  revolt  and  incite  the  others  to  robbery,  and  their 
indecent  savage  ways,  as  well  as  the  terrible  reputation  which  often  pre- 
cedes them,  make  them  objects  of  terror  and  repulsion  to  the  quieter  patient 
and  their  relatives,  who  dread  to  see  their  kin  in  such  company. 

The  medical  examination  of  prisoners  would  make  it  neces- 
sary for  every  penal  institution  to  have  a  psychopathic  depart- 
ment in  those  states  which  are  without  a  separate  hospital  for  the  care 
of  the  criminal  insane,  for  the  care  of  those  persons  charged  with 
crime  who  are  found  insane  at  the  time  of  trial,  and  for  those 
prisoners  whose  state  of  mental  enfeeblement  makes  it  impossi- 
ble for  them  to  adjust  themselves  with  safety  to  all  concerned 
to  the  routine  of  prison  life.  This  conception  of  providing  an 
institution  for  this  class  of  irresponsible  offenders  against  the 
penal  law  is  slowly  permeating  the  social  conscience  and  there 
are  now  about  twelve  such  institutions  in  the  United  States. 
Our  country  has  been  extremely  slow  in  recognizing  the  need  of 
such  institutions  and  the  honor  of  establishing  them  belongs  to 
England.  A  department  for  the  special  care  of  the  criminal  in- 
sane was  instituted  in  1786  at  the  Bedlam  Asylum.  Later,  in 
1850,  another  one  was  opened  at  Dundrum,  Ireland.  In  1858, 
such  an  institution  was  set  aside  at  Perth,  Scotland,  and  the 
famous  Broadmore  Hospital  came  into  existence  in  1863. 

The  individuals  sent  to  the  hospitals  for  the  criminal  insane 
should  remain  there  until  they  cease  to  be  a  source  of  danger  to 
be  at  large.  Their  period  of  incarceration  should  be  permanent 
unless  a  cure  is  affected.  It  goes  without  saying  that  these  hospi- 
tal or  psychopathic  annexes  to  prisons  should  be  in  the  control 
of  alienists  who  have  had  experience  in  the  care  of  prisoners  as 
well  as  the  insane. 

The  law  governing  the  commitment  of  persons  to  a  hospital 
for  the  criminal  insane  should  be  so  constructed  that  its  consti- 
tutionality cannot  be  questioned.     It  should  be  so  drawn  that 


227 

while  the  individual  prisoner  will  receive  all  due  protection, 
society  will  also  be  protected  from  the  person  mentally  responsi- 
ble, but  who  seeks  to  evade  the  responsibility  of  criminal  acts 
by  a  plea  of  insanity.  The  law  on  this  subject  should  embrace 
the  following  principles:  If  it  should  be  found  by  the  court 
alienist  that  the  alleged  criminal  was  suffering  with  insanity  at 
the  time  of  the  commission  of  his  criminal  act  and  by  reason 
of  his  mental  unbalance  the  criminal  intent  to  commit  a  crime 
was  lacking,  he  should  not  be  convicted  or  punished.  But  he 
should,  for  the  safety  and  welfare  of  society,  be  confined  in  a  hos- 
pital for  the  criminal  insane  until  his  sanity  is  so  restored  that  he 
would  no  longer  be  dangerous  and  not  until  then.  Or,  if  it  should 
be  found  by  examination  that  the  defendant  had  been  insane 
at  the  time  of  the  commission  of  his  dangerous  act,  but  that  he 
was  sane  at  the  time  of  trial  and  that  a  recurrence  of  his  insanity 
is  highly  probable,  he  should  be  committed  to  a  hospital  for  in- 
sane criminals  for  a  long  period  of  observation  and  treatment. 

In  order  to  further  safeguard  the  integrity  and  to  guarantee 
the  reliability  of  the  medical  examination  of  prisoners  which  has 
been  advocated  in  this  paper  that  it  ma}^  be  thoroughly  scientific, 
reliable  and  fair,  the  court  alienists  must  be  chosen  from  a  quali- 
fied group  of  physicians  who  by  reason  of  their  training,  experience 
and  integrity  are  fitted  for  this  important  work.  Political  in- 
fluence must  be  absolutely  barred  in  the  selection  of  official  ex- 
perts that  the  desired  end  may  not  be  frustrated.  The  individuals 
eligible  to  appointment  should  be  designated  by  the  state  medical 
society. 

If  medical  examination  of  prisoners  was  instituted  as  a  matter 
of  routine  practice  in  our  criminal  courts,  a  very  material  im- 
provement would  follow  for  the  following  reasons: 

a.  The  ordinary  insane  persons  would  be  separated  from  the 
usual  class  of  criminals  and  the  mentally  sick  could  be  given  the 
proper  treatment  in  the  proper  institutions  early  in  the  coiurse 
of  their  diseases. 

b.  The  dangerous  insane,  the  morally  insane,  the  sexual  per- 
verts, and  the  habitual  criminals  would  be  segregated  and  sent  to 
hospitals  for  the  criminal  insane  permanently  or  until  a  cure 
was  affected. 


228 

c.  Prisons  would  cease  to  be  a  dumping  ground  for  all  classes 
of  defectives. 

d.  Society  would  be  very  much  better  protected  than  it  is  now, 
for  mental  defectives  and  habitual  criminals  would  not  be  released 
to  fiui:her  prey  upon  the  public. 

e.  There  would  be  an  enormous  saving  of  money  now  uselessly 
spent  in  needless  trials  of  incurable  defective  delinquents. 

/.  Much  valuable  data  concerning  criminalistics  would  be  ac- 
cumulated that  would  put  our  criminal  procedure  on  a  more 
rational  basis  than  exists  at  present. 

DISCUSSION. 

Dr.  Tom  A.  WilHams,  Washington,  D.  C: 

On  account  of  the  lack  of  personal  experience  in  this  field  my  acceptance 
of  the  invitation  of  the  Chairman  of  the  Program  Committee  will  have  to 
consist  of  a  number  of  truisms  only.  I  am  very  sorry  that  I  cannot  contribute 
anything  at  all  to  the  discussion.  The  first  truism  is  that  if  the  person  is 
sick  to  the  point  of  interference  with  judgment  or  will,  he  may  not  be  liable 
before  the  court.  Therefore  he  should  be  examined  to  determine  his  responsi- 
bility before  the  court  term  rather  than  during  or  after  the  trial.  The  ex- 
amination of  a  prisoner  should  be  made  not  by  a  partisan  but  by  an  expert. 
The  expert's  attitude  toward  the  prisoner  must  be  one  of  sympathy  rather 
than  judicial  solemnity.  It  is  the  province  of  the  physician  merely  to  diag- 
nose, not  to  say  anything  about  the  disposition;  the  verdict  is  a  matter  for 
the  court,  and  depends  upon  the  law  at  the  time  of  the  trial.  We  doctors 
see  further  than  the  lawyer,  but  we  forget  that  the  lawyer  is  administering 
that  already  written  in  the  statutes;  he  cannot  go  beyond  that  which  is  writ- 
ten down  in  the  law.  A  great  objection  made  by  lawyers  in  criminal  cases 
to  this  procedure  (examination  of  the  mentality)  is  on  the  groimd  of  personal 
rights.  In  insane  cases,  however,  it  is  the  business  of  the  state  to  examine 
the  condition  of  the  patient  and  deal  with  him  accordingly.  There  is  no  new 
abrogation  of  personal  rights  when  it  is  the  state  which  acts  in  that  capacity 
toward  the  criminal  who  may  be  insane. 

It  is  a  truism  that  if  a  person  is  diseased  to  the  point  of  serious  interference 
with  perception,  judgment  or  will,  that  he  cannot  be  held  responsible  before 
the  court.  The  rational  course  is  therefore  to  ascertain  responsibility  before 
court  trial. 

The  very  nature  of  a  crime  may  make  it  sufficient  to  show  that  its  author 
is  insane.  For  instance:  self-depreciation,  or  boasting  of  lack  of  any  precau- 
tions or  ridiculous  purposelessness  are  in  themselves  evidence  of  mental 
unbalance,  as  is  an  accompaniment  of  maniacal  fury  or  a  sudden  impulsion. 


229 

The  physical  condition  may  raise  a  presumption  of  insanity,  as  in  puerperal 
infanticide,  alcoholism  or  the  menstrual  epoch  which  often  is  the  determining 
cause  of  impulsions  to  steal,  arson  and  fugue  or  epilepsy,  which  tends  to  crimes 
of  violence  with  amnesia. 

Delusional  ideas,  of  course,  are  presimiptuous  of  irresponsibility,  especially 
where  they  are  religious,  persecutory,  litigious  or  political.  This  is  especially 
so  in  early  states  of  general  paralysis. 

Psychological  disturbances,  such  as  that  of  the  pathological  liar,  have  to 
be  considered,  too. 

The  examination  of  a  prisoner  should  be  made  not  by  a  partisan  but  by  an 
expert,  that  is  to  say,  a  person  really  qualified  to  make  an  impartial  estimate 
of  the  prisoner's  status  medico-psychologically.  The  expert's  attitude 
towards  the  prisoner  must  be  one  of  sympathy  rather  than  one  of  judicial 
solemnity;  otherwise  the  subject  will  scarcely  be  able  not  to  conceal  his  real 
thought  because  of  fear  or  definace.  The  latter  is  particularly  difiScult  to 
disarm  in  the  systematised  delusional  insane,  who  are  endeavoring  to  dis- 
simulate their  morbid  ideas. 

The  contrary  type,  those  who  simulate  insanity,  must  also  be  guarded 
against  by  the  expert.  But  it  is  very  difficult  to  deceive  an  experienced 
psychiatrist  in  this  respect.  For  no  insane  individual  is  absurd  in  every- 
thing. This  intentional  absm-dity  of  answer,  the  sly  look,  the  lack  of  a  proper 
expression  of  excitement  or  indifference  or  true  melancholy  or  stupidity  or 
of  pride  or  inattention,  the  absence  of  the  denial  of  his  insanity,  along  with 
the  lack  of  such  physical  concomitants  as  insomnia,  relativ  analgesia,  constipa- 
tion, capricious  appetite,  or  the  modification  of  the  temperatm-e,  pulse,  respira- 
tion and  vaso-motor  innervation  will  make  the  examiner  very  chary  of  de- 
claring a  prisoner  insane;  and  sedulous  observation  will  then  surely  unmask 
the  simulator. 

The  declaration  that  every  simulator  is  ipso  facto  insane  is  only  possible 
by  stretching  of  the  word  insane  to  comprise  every  mental  abnormality; 
whereas  insanity  is  merely  a  convenient  term  of  jurisprudence  to  apply  to 
those  persons  adjudged  incapable  of  managing  themselves  and  therefore  not 
responsible  to  society  for  their  behavior. 

Dr.  James  H.  McBride,  Pasadena,  Cal.: 

Many  people  are  of  course  bom  with  a  predisposition  to  insanity  who  have 
had  no  immediate  insane  ancestors,  and  for  this  reason  we  should  give  heredity 
in  insanity  a  wide  interpretation.  If  all  the  pronounced  hereditary  insanity 
were  to-day  swept  away,  the  disorder  would  continue  to  occur,  because  the 
conditions  that  produce  brain  degeneracy  and  insanity  are  always  acting. 
The  great  majority  of  the  cases  of  insanity  come  from  the  homes  of  the  poor 
where  poor  food,  over-crowding,  and  other  degrading  conditions  associated 


230 

with  extreme  poverty,  act  to  produce  insanity  and  allied  conditions  such  as 
feeble-mindedness,  prostitution,  criminality,  and  physical  disease. 

The  chief  causes  of  insanity  are  at  bottom  economic,  and  bad  housing  is 
the  more  common  visible  form  of  bad  economic  conditions.  The  slum  and 
the  near  slum  and  the  unhealthy  influences  associated  with  them  are  responsi- 
ble for  an  immense  amount  of  physical  disease  and  mental  disorder. 

The  sltun  conditions  of  oiu:  cities,  and  those  of  our  villages  and  farms, 
which  are  not  uncommon,  are  yearly  sending  their  victims  by  thousands  to 
our  insane  asylums.  Insanity  will  continue  to  increase  until  these  condi- 
tions are  remedied.  We  will  reduce  the  amoimt  of  occurring  insanity  when 
we  recognize  that  the  causes  of  the  disorder  are  largely  economic,  and  act 
accordingly,  and  not  till  then.  All  our  fine  talk  about  the  moral  and  mental 
causes  of  insanity  really  means  httle.  They  need  to  be  related  to  the  plain, 
every-day  influences  of  the  individual's  home,  those  influences  that  make 
or  unmake  health  and  character. 

I  am  glad  Dr.  Wilbur  spoke  of  the  commitment  of  the  insane.  The  Con- 
stitutional provision  that  no  one  shall  be  deprived  of  liberty  without  due 
process  of  law,  means  that  a  jury  trial  is  necessary  to  confine  an  insane  per- 
son, and  many  of  the  states  have  held  that  the  certificate  of  two  physicians 
and  a  court  of  record  constitute  a  sufficient  jury  in  the  case  of  an  insane 
person. 

Dr.   Hutchings: 

The  subject  of  heredity  is  one  upon  which  authorities  differ  more  or  less 
and  I  am  glad  that  it  was  referred  to  in  the  discussion.  We  have  insufficient 
data  relative  to  heredity  to  justify  us  in  basing  any  definite  opinion  and  for 
that  reason  I  have  deliberately  turned  away,  in  my  own  work,  from  attaching 
much  importance  to  it.  After  all,  heredity  means  only  this:  that  here  is  a 
person  who  should  take  better  care  of  himself  in  certain  ways  because  he 
has  probably  inherited  a  nervous  system  which  cannot  stand  as  much  strain 
in  the  way  of  bad  habits  of  living  from  the  standpoint  of  the  physical  health 
or  from  bad  mental  habits,  such  as  worry,  fretting,  etc.  Once  the  situation 
is  understood  and  the  individual  is  taught  how  to  take  care  of  himself,  even 
a  bad  heredity  need  not  necessarily  result  in  mental  trouble.  It  is  far  more 
practical  to  devote  our  attention  to  the  precipitating  causes  and  deal  with 
them  in  some  definite  way  than  to  allow  ourselves  to  become  stifled  by  the 
predestination  idea  that  attaches  to  heredity. 

Reference  was  made  to  the  matter  of  commitment.  In  many  cases  com- 
mitment is  unnecessary.  The  patient  can  be  persuaded  by  his  relatives  to 
come  to  the  hospital  voluntarily  and  admissions  of  this  sort  ought  to  be  en- 
couraged. The  way  into  the  hospital  and  the  way  out  of  the  hospital  should 
be  made  easy.  We  should  approach  as  near  as  we  can  to  the  general  hospital 
in  that  respect.  Still  I  recognize  that  commitment  will  be  necessary  in  a 
considerable  number  of  cases  of  paranoiacs  and  others  lacking  insight,  who 


231 

would  refuse  to  come  to  the  hospital  voluntarily  or  who  after  they  come 
would  refuse  to  remain  and  who  might  be  dangerous  to  themselves  or  others. 

Dr.  Bowers: 

The  system  of  the  Simon-Benet  examination  has  been  a  delectable  morsel 
for  the  public  palate;  newspapers  and  popular  jom^als  have  been  over- 
flowing with  articles  upon  the  value  of  this  system.  I  am  not  unaware  of 
the  valuable  work  being  done  under  this  scale  of  mental  measurement  but 
grievous  mistakes  are  made  when  it  is  not  employed  by  adequately  trained 
specialists. 


INDEX 

Accidents,   Social  insurance  against —  (workmen's  compensation  laws). 

Frederick  L.  Van  Sickle,  M.D.,  Olyphant,  Pa 54 

Andrews,  John  B.,  Ph.D.,  New  York  City.     Health  insurance 77 

Baldy,  John  M.,  M.D.,  Philadelphia.  Examination  for  license  to  prac- 
tise and  hospital  intemeship 37 

Biggs,  Hermann  M.,  M.D.,  Albany,  N.  Y.  The  New  York  State  sani- 
tary code,  how  enacted  —  its  scope  and  legal  status 125 

Bowers,  Paul,  M.D.,  Michigan  City,  Ind.     The  necessity  for  medical 

examination  of  prisoners  at  the  time  of  trial 220 

Child  labor.  Standards  applicable  to  — .     Helen  L.  Sumner,  Ph.D., 

Washington,  D.  C 164 

Children,  Our  social  readjustments  and  the  relation  of  the  state  to 

motherhood  and  — .     George  A.  Hare,  M.D.,  Fresno,  Cal 7 

Civil  positions.  Legislation  creating  —  for  physicians.     John  B.  Mc- 

Alister,  M.D.,  Harrisburg,  Pa 46 

Colwell,  N.  P.,  M.D.,  Chicago.     Legislation  regulating  the  practice  of 

medicine,  preliminary  and  medical  education 24 

Defective,  The  physically  — .     E.  O.  Otis,  M.D.,  Boston 189 

Drink  problem  and  legislation,  The.     John  Koren,  A.B.,  Boston 140 

Education,  Legislation  regulating  the  practice  of  medicine,  preliminary 

and  medical  — .     N.  P.  Colwell,  M.D.,  Chicago 24 

Evils,  Legislative  protection  of  the  people  from  the  —  of  patent  medi- 
cines and  medical  fakers.  F.  F.  Lawrence,  M.D.,  D.Sc,  LL.D., 
F.A.C.S.,  Columbus,  O 154 

Examinations  for  license  to  practise  and  hospital  interneship.     John  M, 

Baldy,  M.D.,  Philadelphia 37 

Hare,  George  A.,  M.D.,  Fresno,  Cal.     Our  social  readjustments  and  the 

relation  of  the  state  to  motherhood  and  children 7 

Health  insurance.     John  B.  Andrews,  Ph.D.,  New  York  City 77 

Health  insurance.  The  relation  of  medical  benefits  of  —  to  existing  health 

agencies.     B.  S.  Warren,  M.D.,  Washington,  D.  C iii 

Housing  reform  through  legislation.     Lawrence  Veiller,  New  York.  ...      179 

Hutchings,  Richard  H.,  M.D.,  Ogdensburg,  N.  Y.     The  state  and  the 

insane 209 

Industries,  Medicine  and  the  — .     George  M.  Price,  M.  D.,  New  York 

City 183 

Insane,  The  state  and  the  — .  Richard  H.  Hutchings,  M.D.,  Ogdens- 
burg, N.  Y 209 

Insurance,  Health  — .     John  B.  Andrews,  Ph.D.,  New  York  City 77 

Insurance,  Social  —  against  accidents  (workmen's  compensation  laws). 

Frederick  L.  Van  Sickle,  M.D.,  Olyphant,  Pa 54 


233 

Insurance,  The  relation  of  medical  benefits  of  health — to  existing  health 

agencies.     B.  S.  Warren,  M.D.,  Washington,  D.  C iii 

Insurance,  Unemployment  — .     Rufus  M.  Potts,  Springfield,  111 90 

Interneship,  Examination  for  license  to  practise  and  hospital  — .     John 

M.  Baldy,  M.D.,  Philadelphia 37 

Interstate  sanitary  relations.  William  Colby  Rucker,  M.D.,  Washing- 
ton, D.  C 131 

Kelley,  Mrs.  Florence,  New  York  City.     Women  as  wage-earners 176 

Koren,  John,  A.B.,  Boston.     The  drink  problem  and  legislation 140 

Lawrence,  F.  F.,  M.D.,  D.Sc,  LL.D.,  F.A.C.vS.,  Columbus,  O.  Legisla- 
tive protection  of  the  people  from  the  evils  of  patent  medicines  and 
medical  fakers 154 

Legislation  creating  civil  positions  for  physicians.     John  B.  McAlister, 

M.D.,  Harrisburg,  Pa 46 

Legislation,  Housing  reform  through  — .     Lawrence  Veiller,  New  York 

City 179 

Legislation  regulating  the  practice  of  medicine,  preliminary  and  medical 

education.     N.  P.  Colwell,  M.D.,  Chicago , 24 

Legislation,  The  drink  problem  and — .     John  Koren,  A.B.,  Boston.  ..  .      140 

Legislative  protection  of  the  people  from  the  evils  of  patent  medicines 
and  medical  fakers.  F.  F.  Lawrence,  M.D.,  D.Sc,  LL.D.,  F.A.C.S., 
Columbus,  O 154 

License,   Examinations   for   —  to   practise   and  hospital   interneship. 

John  M.  Baldy,  M.D.,  Philadelphia 37 

McAlister,  John  B.,  M.D.,  Harrisburg,  Pa.     Legislation  creating  civil 

positions  for  physicians 46 

Medical  benefits.  The  relation  of  —  of  health  insurance  to  existing 

health  agencies.     B.  S.  Warren,  M.D.,  Washington,  D.  C 11 1 

Medical  examination,  The  necessity  for  —  of  prisoners  at  the  time  of 

trial.     Paul  Bowers,  M.D.,  Michigan  City,  Ind 220 

Medical  fakers.  Legislative  protection  of  the  people  from  the  evils  of 
patent  medicines  and  — .  F.  F.  Lawrence,  M.D.,  D.Sc,  LL.D., 
F.A.C.S.,  Columbus,  O 154 

Medicine  and  the  industries.     George  M.  Price,  M.D.,  New  York  City.      183 

Medicine,  Legislation  regulating  the  practice  of  — ,  preliminary  and 

medical  education.     N.  P.  Colwell,  M.D.,  Chicago 24 

Motherhood,  Our  social  readjustments  and  the  relation  of  the  state  to  — 

and  children.     George  A.  Hare,  M.D.,  Fresno,  Cal 7 

Necessity  for  medical  examination  of  prisoners  at  the  time  of  trial,  The. 

Paul  Bowers,  M.D.,  Michigan  City,  Ind 220 

New  York    State   sanitary   code,  how    enacted — its   scope   and   legal 

status.  The.      Hermann  M.  Biggs,  M.D.,  Albany,  N.  Y 125 

Otis,  E.  O.,  M.D.,  Boston.     The  physically  defective 189 

Our  social  readjustments  and  the  relation  of  the  state  to  motherhood 

and  children.     George  A.  Hare,  M.D.,  Fresno,  Cal 7 


234 

Patent  medicines,  Legislative  protection  of  the  people  from  the  evils  of 
—  and  medical  fakers.     F.   F.   Lawrence,   M.D.,   D.Sc,  LL.D. 

F.A.C.S.,  Columbus,  O 154 

Physically  defective.  The.     E.  O.  Otis,  M.D.,  Boston 189 

Physicians,  Legislation  creating  civil  positions  for  — ,     John  B.  Mc- 

Alister,  M.D.,  Harrisbturg,  Pa 46 

Potts,  Rufus  M.,  Springfield,  111.     Unemployment  insurance 90 

Practice,    Examinations   for   license   to   —   and   hospital   interneship. 

John  M.  Baldy,  M.D.,  Philadelphia 37 

Practise  of  Medicine,  Legislation  regulating  the  — ,   preliminary  and 

medical  education.     N.  P.  Colwell,  M.D.,  Chicago 24 

Price,  George  M.,  M.D.,  New  York  City.     Medicine  and  the  industries.     183 
Prisoners,  The  necessity  for  medical  examination  of  —  at  the  time  of 

trial.     Paul  Bowers,  M.D.,  Michigan  City,  Ind 220 

Relation  of  medical  benefits  of  health  insurance  to  existing  health  agen- 
cies. The.     B.  S.  Warren,  M.  D.,  Washington,  D.  C 11 1 

Rucker,  William  Colby,  M.D.,  Washington,  D.  C.     Interstate  sanitary 

relations 131 

Sanitary  code,  The  New  York  State  — ,  how  enacted — its  scope  and 

^v  ^  legal  status.     Hermann  M.  Biggs,  M.D.,  Albany,  N.  Y 125 

Sanitary    relations,    Interstate    — .     WiUiam    Colby    Rucker,    M.D., 

Washington,  D.  C 131 

Social   insurance   against   accidents    (workmen's   compensation   laws). 

^'^^  Frederick  L.  Van  Sickle,  M.D.,  Olyphant,  Pa 54 

Standards  applicable  to  child  labor.     Helen  L.  Sumner,  Ph.D.,  Wash- 
ington, D.  C 164 

State  and  the  insane,  The.     Richard  H.  Hutchings,  M.D.,  Ogdensburg, 

N.  Y 209 

State,  Our  social  readjustments  and  the  relation  of  the  —  to  motherhood 

and  children.     George  A.  Hare,  M.D.,  Fresno,  Cal 7 

Sumner,  Helen  L.,  Ph.D.,  W^ashington,  D.  C.     Standards  applicable  to 

child  labor 164 

Trial,  The  necessity  for  medical  examination  of  prisoners  at  the  time  of 

— .     Paul  Bowers,  M.D.,  Michigan  City,  Ind 220 

Unemployment  insurance.     Rufus  M.  Potts,  Springfield,  111 90 

Van  Sickle,  Frederick  L.,  M.D.,  Olyphant,  Pa.     Social  insurance  against 

accidents  (workmen's  compensation  laws) 54 

Veiller,  Lawrence,  New  York  City.     Housing  reform  through  legisla- 
tion      179 

Wage-earners,  Women  as  — .     Mrs.  Florence  Kelley,  New  York  City.  .     176 
Warren,  B.  S.,  M.D.,  Washington,  D.  C.     The  relation  of  medical  bene- 
fits of  health  insurance  to  existing  health  agencies iii 

Women  as  wage-earners.     Mrs.  Florence  Kelley,  New  York  City 176 

Workmen's  compensation,  Social  insurance  against  accidents  ( —  laws). 

Frederick  L.  Van  Sickle,  M.D.,  Olyphant,  Pa 54 


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